Tag Archives: sleep

The darker side of sleep

By David Engstrom January 6, 2021

“Sleep is the golden chain that ties health and our bodies together.” — Thomas Dekker, 1625

“Without enough sleep, we all become tall 2-year-olds.” — JoJo Jensen, Dirt Farmer Wisdom, 2002

“I love sleep. I’d sleep all day if I could.” — Miley Cyrus, 2019

To me, making those elusive connections between events, experiences and symptoms in our clients’ lives is one of the most exciting parts of counseling. There may be no clearer connection between the mind and body than sleep.

How do you sleep? More importantly, do you know how your clients sleep? When we evaluate our clients’ histories and experiences, one area of behavioral health that is easy to ignore or minimize is sleep. But disturbed sleep is very common among Americans and is connected to many psychological and physical health problems later in life. A more comprehensive assessment may lead to important clues about an experience of early trauma and abuse.

Sarah: Initial assessment

As a consultant at a hospital sleep disorders center in Arizona, I saw “Sarah,” a 30 year-old Hispanic woman who was referred because of severe insomnia. She reported great difficulty falling asleep, and even after she did, she often slept no more than three hours per night, with frequent awakenings.

Sarah was married, had no children and worked as a university professor. She claimed that her marriage was “strong and supportive,” and she greatly loved her work as a professor. She had been prescribed benzodiazepine sleeping medications two years prior, but they were no longer helping, and Sarah feared she was becoming dependent on them.

Sarah was in good physical health but was concerned that she had gained 35 pounds over the course of five years. She had never before seen a mental health professional. Her prior overnight visit to the hospital sleep disorders center had revealed major difficulties in initiating and maintaining sleep. Polysomnographic results confirmed that she took 82 minutes to fall asleep initially and that she experienced five awakenings of greater than 20 minutes each during the night. Her total sleep time was 2.7 hours.

Her sleep problems had been present and worsening since high school, or a span of about 15 years. She presented with severe daytime sleepiness, anxiety and depression. Sarah stated, “I can’t go on like this.”

Sleep facts

Studies from the Centers for Disease Control and Prevention (CDC) reveal the following data about healthy sleep duration (with higher percentages indicating healthier durations):

Geography: Prevalence of healthy sleep duration ranged from 56% in Hawaii to 72% in South Dakota.

Percentage of healthy sleep duration by race/ethnicity: Native Hawaiian/Pacific Islanders (54%); Black (54%); Other/Multiracial (54%); American Indian/Alaska Native (60%); Asian (63%); Hispanic (66%); White (67%)

Although requirements vary slightly from person to person, most healthy adults need seven to nine hours of sleep per night to function at their best. Children and teenagers need even more. Despite the notion that our sleep needs decrease with age, people older than 65 still need at least seven hours of sleep per night. Interestingly, the average total nightly sleep duration fell from approximately nine hours in 1910 to approximately seven hours in 2002.

Prevalence of disturbed sleep

Sleep disturbance is a common problem that affects at least 75% of Americans at some point in their lives. Among the various sleep disorders, approximately 33% of all adults suffer from an insomnia disorder, which can have significant negative consequences if left untreated. Individuals who struggle with chronic insomnia often describe their condition as a “vicious cycle,” with increasing effort and desire put into trying to regain sleep, with negative results.

A 2014 survey conducted by the National Sleep Foundation reported that 35% of American adults rated their sleep quality as “poor” or “only fair.” Difficulty falling asleep (onset insomnia) at least one night per week was reported by 45% of respondents. In addition, 53% had experienced trouble staying asleep (early awakening or maintenance insomnia) at least one night of the previous week, and 23% had experienced trouble staying asleep on five or more nights. Research suggests that sleep problems are worse among women but increase in both genders with age.

Any of us can do a self-assessment of our sleep deprivation, also known as “sleep debt.” You probably have sleep debt if you 1) find yourself drowsy or sleepy during the day, 2) frequently need an alarm clock to awaken and 3) fall asleep very rapidly (less than five minutes) when you go to bed.

Insomnia is not a disease; it is a symptom. It may be 1) associated with medical problems, 2) associated with psychological problems, 3) due to lifestyle, 4) caused by poor sleep habits or 5) any combination of the above.

Sleep deprivation can have many effects, both physically and psychologically. In the short term, it can lead to stress, somatic problems, cognitive difficulties, anxiety and depression. Long-term effects can include cardiovascular disease, obesity, diabetes, cancer and even early death.

Hypnotic medications are frequently used to treat insomnia, but many patients prefer non-drug approaches to avoid dependence and tolerance.

Assessment of sleep disorders

The self-administered Pittsburgh Sleep Quality Index assesses seven components of sleep based on clients’ self-reports. This widely used instrument has been shown to reliably detect clinical levels of sleep disruption in adults across a broad range of ages. Areas assessed include subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbance, use of sleeping medications and daytime dysfunction.

On a more practical level, I have found that having clients keep a simple “sleep log” for two weeks can help to identify sleep problems. I have clients record:

  • The time they go to bed
  • Medication taken (if any)
  • Estimated time to fall asleep (onset)
  • Estimated number of awakenings during sleep
  • Wake-up time
  • Estimated total sleep time
  • Sleep quality (0-10 scale)
  • Daytime alertness (0-10 scale)
  • Level of worry about sleep (0-10 scale)

Sarah: Sleep assessment

Sarah was provided sleep self-monitoring materials to complete over 14 days. Results clearly indicated many awakenings during the night, short sleep times and profound daytime sleepiness. These results were confirmed by polysomnographic data. Assessment results indicated diagnosis of insomnia disorder (780.52/307.42), Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5).

Assessment of childhood trauma

Systematic assessment of childhood trauma has evolved since the original study of adverse childhood experiences (ACEs) by the CDC and Kaiser Permanente in the mid-1990s.

ACEs are classified in three different subsets: abuse (physical, emotional, sexual); neglect (physical, emotional); and household dysfunction (mental illness, incarcerated relative, parent treated violently, substance dependence, divorce). These 10 areas can be incorporated into a structured interview, with questions such as “Before your 18th birthday, did you often or very often feel that you didn’t have enough to eat? Had to wear dirty clothes? Had no one to protect you? That your parents were too drunk or high to take you to the doctor if you needed it? Before your 18th birthday, was a household member depressed or mentally ill, or did a household member attempt suicide?” These questions can easily be incorporated into a routine clinical interview.

In a large study, 61% of adults had at least one ACE, and 16% had four or more types of ACEs. Women and members of several racial/ethnic groups were at greater risk for experiencing four or more ACEs. Exposure to ACEs is associated with increased risk for many health problems across the life span.

As counterpoint, Jack Shonkoff, a pediatrician and director of the Center on the Developing Child at Harvard University, notes “there are people with high ACE scores who do remarkably well.” Resilience, he says, builds throughout life, and close relationships are key. This implies that the ACE score for an individual is not a static number, but more dynamic, because personality traits and life experiences can modify the impact of ACEs.

Effects of childhood trauma and abuse on sleep

In a major population-based study in 2011, Emily Greenfield et al. found that three classes of abuse history were highly associated with a greater risk of global sleep pathology:

1) Frequent physical and emotional abuse with sexual abuse

2) Frequent physical and emotional abuse without sexual abuse

3) Occasional physical and emotional abuse with sexual abuse

The most extreme class of abuse — frequent physical and emotional abuse with sexual abuse — was associated with poorer self-reported sleep across many components measured, including subjective sleep quality, greater sleep disturbances and greater use of sleep medication.

Adults who reported frequent experiences of childhood physical and emotional abuse — regardless of sexual abuse — were found to be at especially high risk for global sleep pathology. Regardless of their experiences of sexual abuse, respondents who reported frequent experiences of physical and emotional abuse were over 200% more likely than respondents who reported no abuse to have clinically relevant levels of sleep pathology.

In 2018, Ryan Brindle et al. concluded that “childhood trauma may affect sleep health in adulthood. These findings align with the growing body of evidence linking childhood trauma to adverse health outcomes later in life.” Furthermore, trauma exposure after age 18 and across the life span did not relate to sleep health, suggesting that trauma experienced at a younger age is a more important factor.

Sarah: Trauma assessment

In gathering Sarah’s history during the first several sessions, she reluctantly revealed that she had been sexually molested repeatedly by her mother’s live-in boyfriend between the ages of 11 and 15. He was apparently dependent on alcohol and other drugs, with Sarah stating that he seemed “drunk most of the time.” She recalled that these events occurred “about twice a month” and consisted of mutual (subtly coerced) sexual touching and fondling, including occasional oral sex but no intercourse. Sarah never revealed this to her mother. Sarah’s obtained ACEs score was five. This finding suggested a second working diagnosis of trauma and stressor-related disorder in the DSM-5.

Possible mechanisms

In theory and research evidence, there is a fairly clear link between chronic stress and increased production of the hormone cortisol, which in turn can accelerate inflammation in the body. This may be a factor that can help explain the trauma-sleep connection.

Stress: In discussing trauma and sleep in children, Avi Sadeh suggested (1996) that stress was among the most powerful contributors to poor sleep. This can include significant life changes/events or threats that demand physiological, behavioral and psychological resources to maintain “psychophysiological equilibrium and well-being.”

Cortisol: Cortisol is produced by the adrenal glands, and high levels of physical or psychological distress lead to increases in cortisol secretion. In a study by Nancy Nicolson et al. (2010), emotional and sexual abuse were most closely linked to increased cortisol levels. Childhood maltreatment is also associated with elevated cortisol.

For clients living with stress and insomnia, cortisol levels remain elevated above normal levels, especially during sleep. With sustained levels of higher cortisol, these individuals remain in a state of hyperarousal, even when they’re asleep, thereby disrupting the overall quality and restfulness of their sleep. Chronic “short sleepers” (those who get five to six hours of sleep per night) have higher levels of nocturnal cortisol secretion in comparison with “normal sleepers” (those who get seven to eight hours of sleep per night).

Inflammation: Research by Janet Mullington et al. (2010) indicates that long-term inflammation may be the common factor in many chronic diseases. Social threats and stressors can drive the development of sleep disturbances in humans, contributing to the dysregulation of inflammatory and antiviral responses.

It is hypothesized that trauma-induced insomnia is a direct result of two interacting variables: physiological hyperarousal and self-defeating cognitive activity.   

Sarah’s treatment

Given that Sarah was suffering from insomnia disorder as well as trauma and stressor-related disorder, it was important to determine which problem needed to be the initial focus of treatment. If we expected that her traumatic history was keeping the insomnia alive, there might have been reason to help her process the trauma first. On the other hand, because her insomnia was having major effects on her mood, concentration and daytime alertness, some justification existed for initially treating her insomnia.

Based on the information obtained about Sarah’s sleep patterns and traumatic history, several evidence-based approaches were used in combination over 11 weekly sessions.

Body scan and breath awareness have both been shown to enhance relaxation prior to sleep. They redirect the mental focus toward the present state of the body and breath. The body scan consists of observing and listening to what bodily sensations are communicating in the moment. It involves noticing areas of tension in the body and inviting these areas to release the tightness.

Breath awareness can consist of slowly accepting the inhale through the nose, deliberately pausing for a moment and then slowly releasing the breath out of the mouth. This regulates the pace of the nervous system and provides an opportunity to mindfully experience the feeling of letting go of what is no longer serving the body. Sarah was provided with audio materials to practice these techniques daily.

Cognitive behavioral therapy for insomnia (CBT-I) is a structured program that aids in identifying and replacing unhelpful thoughts and behaviors that cause or worsen sleep problems with habits that promote sound sleep. CBT-I helps to overcome the underlying causes of sleep problems. It requires the client to keep a detailed sleep diary for one to two weeks. The “cognitive” part of CBT-I teaches clients to recognize and change beliefs that affect their ability to sleep. This type of therapy can help to control or eliminate negative thoughts and worries that keep clients awake.

Sarah recorded her unhelpful automatic thoughts and beliefs about her sleep. These included “Not sleeping well is ruining my life”; “I have to fall asleep right now”; “I’m never going to get over this sleep problem”; and “I am worried that I have lost control of my abilities to sleep.” The A-B-C-D-E system (activating event, belief, consequence, disputation, new effect) was explained to her, and she was instructed in ways to dispute and replace unhelpful thoughts and beliefs. She was successful in describing and challenging these thoughts.

Acceptance and commitment therapy (ACT) is a more recently introduced form of psychotherapy that focuses on mindfulness and acceptance in clients with trauma histories. The underlying theory of ACT is that posttraumatic disorders result from attempting to avoid a past experience at all costs. Thus, a goal of treatment with ACT is to develop more accepting and mindful attitudes toward distressing memories and negative cognitions rather than avoiding them.

Sarah was first introduced to mindfulness as a way to reconnect with the present moment. This built the foundation for increased exposure to avoided thoughts and emotions. Through daily mindfulness practice over 10 weeks, Sarah was able to become aware of painful thoughts that were getting in the way of her sleep and mood. Defusion strategies helped Sarah learn to acknowledge these thoughts as “just thoughts.” Defusion is the separation of an emotion-provoking stimulus from the unwanted emotional response as part of a therapeutic process (think of it as being similar to “defusing” a bomb). Unlike strategies that are more cognitive in nature, the goal is not to challenge thoughts, but rather to acknowledge when thoughts are not helpful, detach from them and move forward. It is not necessary to determine if the thoughts are true or untrue.

One major difference between these two approaches is how unhelpful thoughts are handled. In classic CBT therapy, clients are encouraged to dispute these thoughts and replace them with more helpful ones. In ACT, clients learn to recognize and accept their thoughts but to stand away from them, as is used widely in mindfulness practices.

Outcome of Sarah’s treatment

Following our 11 sessions together, Sarah reported the following:

Although average sleep onset time had decreased only slightly (82 minutes pretreatment to 68 minutes post-treatment), her total sleep time had increased from 2.7 hours to 5.3 hours per night, and her number of awakenings decreased from an average of five per night to one to two per night. She also reported significantly less depression and much more daytime alertness. She was able to go back to work as a full-time university professor.

Summary and takeaways

I have reviewed some important research findings about a potential link between childhood maltreatment and adult insomnia. A case study is presented to help clarify methods for identifying and treating these issues.

In working with people with insomnia over the past 10-plus years, it has become apparent to me that a) many clients who suffer from insomnia do not have (or at least do not disclose) a history of childhood abuse or neglect, and b) among clients who do have a history of abuse as children, some have no apparent sleep problems. Regardless of these outliers, it is clear that sleep patterns should be explored in some depth, and it would be sound clinical practice to always inquire about your clients’ sleep patterns.

 

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David Engstrom lives in Scottsdale, Arizona, and is a core faculty member in the clinical mental health counseling program at the University of Phoenix. A counselor and health psychologist, he is an American Mental Health Counselors Association diplomate in integrated health care. He specializes in weight management, sleep disorders and pain management and is on the medical staff at Honor Health Scottsdale Medical Center. Contact him at David.Engstrom@phoenix.edu.

 

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

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

Finding strength in sensitivity

By Lindsey Phillips September 24, 2019

When Louisa Lombard, a licensed professional clinical counselor in private practice in California, worked as a school counselor, parents would sometimes come to her saying, “My child is so sensitive. I don’t know why he’s like this. Everything is such a big deal. I parent my children the same way. Why is he like this? His brother’s doing great in school and not throwing tantrums and crying. What’s wrong with this kid?”

In actuality, nothing was “wrong” with the child. What the parents didn’t know was that their child had an innate temperament trait referred to as sensory processing sensitivity. Approximately 20% of the population has this sensitivity trait and is categorized as a “highly sensitive person.” Narrow that focus to the therapeutic world, and closer to 50% of psychotherapy clients possess this trait, according to Elaine Aron, a pioneer in the field of sensitivity, in Psychotherapy and the Highly Sensitive Person.

People with this trait often look carefully before entering new situations or retreat from overwhelming ones. For this reason, they are sometimes mislabeled as being shy, when in fact, an estimated 30% of highly sensitive people are extraverted.

Because no one person’s experience is the same, Aron identified four basic characteristics of the highly sensitive person (also known as the DOES model):

  • Depth of processing
  • Overstimulation
  • Emotional responsiveness and empathy
  • Sensitivity to subtleties

Aron points out that the sensory processing sensitivity trait is a survival advantage in some situations because it allows individuals to process information more thoroughly and increases their responsiveness to the environment and social stimuli.

So, why do highly sensitive people — who have this survival advantage — make up roughly 50% of therapy clients? Julie Bjelland, a licensed psychotherapist in private practice in California, thinks the number is so high because highly sensitive people are a) more responsive to therapeutic work and self-help and b) more likely to have higher levels of stress, anxiety and depression.

Heather Smith, an assistant professor of human development counseling at Vanderbilt University, posits that because these individuals process deeply, they are more inclined to seek out answers and are drawn to counseling for its penetrating conversations. In addition, she says, these clients may have developed low self-esteem because of negative stereotypes about sensitivity, or they might want tools to help them navigate times when they feel more emotional intensity.   

Misdiagnosing a trait for a disorder

According to Erica Sawyer, an American Counseling Association member in private practice in Vancouver, Washington, misdiagnosis of the highly sensitive person often occurs because people aren’t aware that the trait exists or of the trait’s specific characteristics. The scientific name for the trait — sensory processing sensitivity — doesn’t help. The similarity in name between sensory processing sensitivity and sensory processing disorder often leads to confusion. But sensory processing sensitivity is a temperament trait, not a disorder. (Aron notes on The Highly Sensitive Person website, hsperson.com, that sensory processing disorder, on the other hand, is a neurological disorder involving the senses.)

As Lombard points out, most therapists receive limited training on temperaments. She first learned about sensory processing sensitivity after graduate school when her oldest daughter started showing signs of the trait, including being sensitive to noise, facial expressions and food. As Lombard learned more, she realized that she is also highly sensitive. She had long suspected that she had attention-deficit disorder because she had a hard time paying attention in her college classes if another student was kicking a desk in a rhythmic pattern behind her or if there was a bright light overhead in the room.

In fact, because highly sensitive people can get overwhelmed and overstimulated more easily when a lot is going on around them, they can commonly be misdiagnosed with attention-deficit/hyperactivity disorder (ADHD), Bjelland says. However, whereas a highly sensitive person is typically able to concentrate in the right environment — when at home in a quiet room, for example — someone with ADHD might not be, she explains.

One confusing aspect to the highly sensitive temperament is that it doesn’t necessarily produce problems in daily life other than overstimulation, says Smith, a licensed professional counselor and an ACA member. Thus, when clinicians hear about a client’s distress due to overstimulation, they can erroneously attribute it to symptoms of a disorder, she explains. To help prevent this, Smith recommends that counselors investigate whether a client’s issue (such as anxiety, stress or an inability to concentrate) decreases if he or she is no longer in an overstimulating environment. If the client’s issue is still present, then it might be a symptom of a disorder.

Smith also points out that counselors often rely on observable behaviors to indicate a possible symptom or disorder. However, depth of processing is not easily observable, she notes. To help counselors learn to identify this characteristic, Smith describes some cues: Highly sensitive people think more about the meaning of life. If in an environment where they are not overstimulated and their ideas are valued, they have the ability to describe all facets of a problem and generate potential prevention steps or solutions — often before others realize there is a problem. They are observers, not the ones to jump into action. They often don’t make decisions quickly. When they speak, it seems as though they have grasped the insight or concept quickly, in large part because they have been thinking about all of these connections for most of their lives.

One tool that can help counselors assess for sensory processing sensitivity is Aron’s 27-item self-test (see hsperson.com/test/highly-sensitive-test). Smith, Julie Sriken and Bradley Erford analyzed the strength of this scale and found it to be a valid screening instrument that counselors can use in their practices (see “Clinical and Research Utility of the Highly Sensitive Person Scale” published in the Journal of Mental Health Counseling.) Smith presented on this topic at the ACA 2019 Conference.

However, to avoid labeling, Smith cautions counselors against placing too great an emphasis on the cutoff score of this self-test. Instead, she recommends having a conversation about how the client marked each item on the scale. This approach focuses less on the total score and more on the person’s experience overall and with each item.

Smith also advises counselors to be careful about interpreting the results from these test items or problem-solving a client’s distress too early on the basis of these initial conversations. In addition to risking misdiagnosis, counselors run the risk of not being seen as credible by clients who have been deeply thinking about issues related to this trait for a while, she says.

Wired differently

Misunderstandings about the sensory processing sensitivity trait also occur when it is assumed that this population is just sensitive to lights and sounds. It is more than that. The brains of highly sensitive people are wired differently than the brains of other people. A 2018 post on the website Highly Sensitive Refuge notes four differences in the brains of highly sensitive people:

  • Their brains respond to dopamine differently.
  • Their mirror neurons (which allow people to “mirror” the behaviors of others and be more empathetic) are more active.
  • They experience emotions more vividly than others (as enhanced by their ventromedial prefrontal cortex).
  • Their brains are more finely tuned to noticing and interpreting other people.

A recent fMRI study published in Brain and Behavior found that highly sensitive people have increased brain activation in regions related to awareness, action planning, empathy, and self-other processing. Lombard, who specializes in working with teenagers and adults who are highly sensitive, shows clients brain scan images from studies such as this one to illustrate how the highly sensitive brain differs in emotional situations such as watching a scary movie or seeing a picture of a loved one. She finds that these images help normalize the trait for clients.

On a podcast for Unapologetically Sensitive, Esther Bergsma, a counselor in the Netherlands and an expert on high sensitivity, reported that highly sensitive people have more brain activation, especially in the areas surrounding social context (e.g., wondering what others think about them, how others view them, or if others accept them). Bergsma pointed out that always being tuned into social contexts is a strength; it is only when people can’t regulate their emotions well that it leads to increased anxiety and stress.

Because people who are highly sensitive have to process more information and can experience nervous system overload as a result, they can be prone to chronic health conditions if they do not have adequate self-care and downtime, says Bjelland, author of The Empowered Highly Sensitive Person: How to Harness Your Sensitivity Into Strength in a Chaotic World.

She likens the way that highly sensitive people deeply process information to cups of water being dumped into the nervous system (“the container”). Highly sensitive people might have 100 cups that they dump into the container, whereas other people have only a few cups to dump. In other words, these individuals notice and process more detail. For example, a highly sensitive child in a classroom might simultaneously notice that a teacher is upset and the happy expression on a classmate’s face across the room and a tree branch tapping against the classroom window.

One way to simplify these brain differences is to think of the brain as two parts: the emotional brain and the cognitive brain. The emotional part of the brain in highly sensitive people is more activated, and if it becomes too activated, the cognitive part of the brain goes to sleep in a sense, Bjelland says. “That’s why [highly sensitive people] might have a hard time with emotional regulation and can get stuck in worry, rumination, anxiety and overwhelm,” she explains. “During times of high stress, the brain cannot tell the difference between a real threat and a perceived threat, so it sends out alarm bells in the system to prepare for fighting or fleeing. In those moments, [highly sensitive people] can’t even access facts, memory and rational thought because that all comes from [the] cognitive brain.”

However, counselors can teach clients ways to reactivate the cognitive brain to support their system and to let the brain know that it isn’t time to send out those alarms, Bjelland continues. For example, she uses a simple breathing technique to calm the body and let the brain know that the person isn’t in danger. Clients breathe in for four counts, hold for two counts, and exhale for seven; they repeat this for about five to seven breath cycles. “The exhale is very long and slow because that sends a signal to your brain that you are not in danger and that it can stop sending out adrenaline and stress hormones. When you exhale slowly, your brain realizes you are OK because that is not how you breathe when you’re in danger,” she explains.

The counting part (whether done out loud or silently) is important because it helps “wake up” the cognitive part of the brain, she adds.

Reframing the perception of sensitivity

As a highly sensitive person herself, Bjelland grew up hearing the negative messages often directed toward people with the sensory processing sensitivity trait: “Why are you so sensitive? What’s wrong with you? Why are you reacting that way?” When people hear those messages as children, she says, they do begin wondering what is wrong with them.

That internalized message is why psychoeducation about the trait is so important, along with validating clients’ experiences. Most highly sensitive people spend their entire lives feeling misunderstood and that something is different about or wrong with them, Bjelland says. Therapy is the place where these clients can begin changing this narrative and turning it into something empowering, she notes.

In her experience working with this population, Bjelland finds that clients often have a transformative experience once they realize that their temperament is normal, that they are not alone, and that they can take steps to improve their experience.

On the other hand, Smith has noticed that some highly sensitive clients experience a grief response after first learning about the trait. They may need time to grieve that they are unlike the other 80% of the population and yet live in a world designed by those without the sensitivity trait, she observes.

Sawyer, a licensed mental health counselor and art therapist, also helps clients reframe their negative experiences, such as being labeled crybabies as children. Counselors can help clients understand that they feel both negative and positive emotions more intensely than other people do. So, when they cried, they were just naturally expressing what they were sensing, which is normal for someone with this trait, she explains.

“They don’t have the problem,” Sawyer says. “It’s the perception that they have a problem that can turn it into one.” So, rather than thinking that they can’t control their emotions, clients can come to understand that with the right support, they can regulate their emotions. They can also take pride in the fact that they feel not only sadness on a deeper level than most people do but also experience incredible happiness, Sawyer says.

Lombard carefully selected the name of her private practice, Strong and Sensitive, to counter the tendency to equate sensitivity with weakness. Many of her clients come in with low self-esteem because of negative stereotypes about being sensitive. She reassures them that it is a normal temperament variation and not a problem. By normalizing the trait, counselors can help clients to embrace it and see it as a strength rather than a weakness, Lombard adds.

Smith teaches clients to more effectively communicate with those who seem to point out sensitivity as a problem. For instance, rather than taking on the onus to defend their sensitivity, clients could ask the other person, “What part of my sensitivity are you having a problem with?” This question reverses the normal assumption that something is wrong with the client’s sensitivity and shifts the conversation to how the other person may need to adjust his or her language or thinking to help problem-solve the relationship dynamic.

Susceptibility to the environment

Research has shown that in a positive developmental environment, highly sensitive children are more likely to thrive than are their peers who are not highly sensitive. However, in a stressful environment, highly sensitive people tend to do worse than do their peers who are not highly sensitive. In other words, this population is highly susceptible to both the good and bad aspects of their environment — a concept known as differential susceptibility.

A highly sensitive person once told Bjelland that when she was younger, her parents made her wear a wool sweater. After repeatedly asking her parents if she could stop wearing it because the material bothered her, they simply replied, “Wear it anyway.” Bjelland notes that this is an example of a highly sensitive person not being supported, and that circumstance can lead to problems.

Bjelland has also noticed that if a highly sensitive child has anxiety, then almost always one or both parents do too. Therapists can’t easily help anxious children if they have an anxious parent, she says, because the child mirrors the parent and will feel unstable if the parent also feels that way.

Parents who are highly sensitive should also be on counselors’ radar because they can suffer from overstimulation and neglect of self-care, Lombard says. The highly sensitive population is also more negatively affected by sleep deprivation, which is common for parents of young children, Lombard notes. She has noticed that highly sensitive parents are sometimes so focused on being the best parents they can be that they don’t take good care of themselves, pumping breast milk constantly or not making time for meaningful adult conversation, for example.

Lombard and Sawyer both recommend that highly sensitive parents get extra support in the form of family members, friends, daycare or a nanny. If finances are an issue, these parents could consider setting up a rotation with another trusted parent to watch each other’s children on occasion, Lombard says. She also encourages highly sensitive parents to wear earplugs or noise-reducing headphones when appropriate because they turn the noise down a bit and can lessen overstimulation.

Other life changes such as a death in the family, menopause, illness or other stressful events can make highly sensitive people feel unbalanced and overwhelmed, especially if they aren’t taking care of themselves, Bjelland says. If they experience too much emotional activation, they may temporarily lose access to the tools and strategies they normally use to cope with overstimulation, she adds.

To counter this, Bjelland tells clients to keep a “positive journal” to record positive events, such as someone saying something nice to them, or techniques that make them feel good, such as going on a hike in nature. Then, when they are having a bad week, they will have a visual record of self-care tips and positive reminders.

The acceptance of sensitivity within a culture also affects one’s environment. Some clients, but especially men, deny having this temperament because society reinforces the idea that sensitivity is not a positive characteristic, Smith says. (Research suggests that the sensory processing sensitivity trait is equal among men and women.) Thus, counselors should be careful about labeling clients as highly sensitive.

Lombard agrees. In fact, if a client grew up in a machismo culture that considers sensitivity to be negative for men, then she might not directly use the term “highly sensitive person” because it may distract from their treatment or therapeutic progress. “Depending on the culture and family of origin, men can carry more shame around [their heightened] sensitivity,” Lombard says. Instead, she mentions that all people have different temperaments and explains that some situations, such as witnessing a car accident, for example, might affect them differently. She also teaches these clients many of the same coping skills without labeling them as being for highly sensitive people.

Bjelland, who is a global educator on this trait and teaches courses for highly sensitive people, doesn’t see as many self-esteem issues in cultures where sensitivity is more accepted. “In the United States where it’s not so accepted, we see a lot of self-esteem issues. And that’s connected to shame too. Most of us walk around with the narrative that something is wrong with us because that’s what we’ve been told,” she says. “Helping to change the client’s narrative to a positive one, where they recognize why this trait is important to the world, is incredibly important.”

Recently, a male client who identified as highly sensitive came to see Sawyer because he needed a safe space to talk. He was struggling to find and maintain a romantic relationship because he found that women often wanted a stereotypical man — someone bold, assertive and athletic. As they talked, Sawyer discovered that he had internalized the belief that being sensitive was negative, which caused his own social anxieties and made relationships even harder for him. After Sawyer reassured the client that he possessed a normal temperament trait and explained its four main characteristics, he felt less self-judgment.

Although simply providing psychoeducation around the trait can be liberating for some clients, counseling often requires a longer process to help clients begin shifting their negative self-perception of being “weak” or “weird,” she adds.

Mindful changes in an overstimulating world

The good news is that highly sensitive people can makes changes so that their lives are more compatible with this trait and they can more readily cope with the challenges posed by living in an often insensitive and overstimulating world.

Bjelland recommends that highly sensitive people carve out two hours of alone time per day and dedicate one complete day each week to downtime. Not surprisingly, many clients balk at this suggestion, saying they don’t have the available time to do that. Bjelland will ask them to try it for one week and, according to her, they will universally report that they had more energy and were more productive because they were more focused, calm and balanced.

Bjelland also advises clients to follow a slower routine in the morning to help set the tone for the day. Why? Think of the nervous system like a motor, she says. If a highly sensitive person jumps out of bed to get the kids ready for school and then races into work, their nervous system revs up, she explains.

The process of slowing down applies to the bedtime routine as well because, as Bjelland points out, this population often struggles with sleep issues. “If a highly sensitive person wakes up from having a good night’s sleep, they get to have their full 100 points of energy for the day, but if they’re having sleep issues, maybe they’re only going to get 50 points for the day, and they’re already starting out depleted,” she says.

She often tells clients to adopt a ritual of doing the same five things before bed, such as taking a warm bath, reading a nonstimulating book, listening to soft music, meditating, and shutting off all electronics. By the time they reach the third action, the brain realizes sleep is coming, she explains.

“You’re teaching them a new type of self-care because [they’ve] been trying to do what the 80% [of the population that is not highly sensitive] are doing, and it’s not working,” Bjelland adds.

Smith agrees that counselors may need to have conversations centered on how self-care for these clients may differ from what rejuvenates other people. For example, if a highly sensitive person tries to relax by going to a concert with lots of lighting and sound effects after work with friends, he or she may instead feel drained and overstimulated by the end of the night.

Overstimulation is a difficult challenge for people with the sensory processing sensitivity trait because they need so much downtime, Lombard points out. She finds mindfulness techniques helpful for teaching these clients how to stay in the moment and self-regulate. For example, a highly sensitive person may find a coffee shop with loud music and people talking overstimulating. However, counseling can provide the client with strategies to successfully navigate such a space. For instance, perhaps the client limits his or her amount of time in the coffee shop or brings noise-canceling headphones, Lombard suggests.

Because these clients feel so deeply, they often need help learning to calm their nervous systems, Lombard continues. Highly sensitive people “are taking in so much more sensory information, and it’s really overwhelming,” she says. “And sometimes [they’re] not even aware, if [they’re] not mindful, of what it was that made [them] feel down or anxious.” She asks her clients to meditate daily using an app such as Calm or Ten Percent Happier and practice breathing techniques to help them become more mindful, present and calm.

Sawyer also suggests that clients use meditation apps such as Headspace or Insight Timer and practice yoga. Sometimes, even the simple act of closing one’s eyes, listening to nature sounds, or going to a quiet spot such as a bathroom or car can be helpful, she adds. The key is finding activities that “help retrain the brain to slow down [and] pay more attention to what’s happening in [the] body,” she says.

Retraining the brain in this way also helps highly sensitive people realize that they have some control and do not have to feel overwhelmed all the time, Bjelland says. For example, every time clients catch their mind wandering during meditation and bring it back to what they’re focusing on, such as their breath, it is like strengthening a muscle. Then, if clients become overwhelmed at work or a large event, they have trained their brains to notice, and they recognize that they need to take a break, she explains.

To help clients exercise this “muscle,” Bjelland instructs them to ask themselves two questions every time they go to the bathroom: 1) How am I doing? and 2) What do I need? This process makes them aware of preventing depletion or overwhelm, she explains. “Highly sensitive people tend to be very externally focused because they’re always scanning the environment for other people’s needs,” Bjelland says. “Most highly sensitive people need to be taught how to explore internally to learn what they need without always filtering it through other people’s needs.”

Of course, the heightened sensitivity to one’s environment also has benefits. Smith has often heard highly sensitive people talk about spending time in nature because there isn’t as much stimulation there. It is a place where they can escape and delight in the beauty of the natural world.

For some highly sensitive people, listening to a bird chirp or watching a sunset can elicit intense feelings of joy or elation, Sawyer says. Spending time in nature — simply walking barefoot in the grass, for example — can also help calm the nervous system, she adds.

Lombard recommends that counselors take these clients outside if they can or, alternatively, bring the natural world into their offices with nature sounds or a water fountain to help create a sense of calm. Lombard has noticed that clients often feel calmer when they see, touch or hear water, so she frequently has clients listen to the sounds of a rainstorm or flowing brook.

Learning to communicate one’s needs

Although highly sensitive people’s empathetic nature often makes them great partners in life and work, relationship issues are one of the primary reasons that they seek counseling. “Highly sensitive people in relationship are going to be so attuned to what the other person is feeling that sometimes they allow that to dominate over their own needs,” Smith says. For example, they may take on more work to please their boss even when they are already overwhelmed.

Smith finds role-play beneficial for helping these clients learn how to assert themselves in relationships. In counseling, they can safely practice communicating their own needs even if it initially seems strange or dramatic to them, she says.

Because highly sensitive people often hold themselves up to the standards of the 80% of the population that is not highly sensitive, they may not be aware that they need more downtime or need to do less so they can maintain their health and wellness, Sawyer says. To help these clients identify their needs and build new habits and coping strategies, she sometimes has them create a values collage of images that speak to them or make them feel good. Through this visual exercise, clients often will discover a common theme, such as nature. The values collage also serves as a reminder of ways that clients can calm an overstimulated nervous system the next time they find themselves in a stressful or overwhelming situation, Sawyer says.

For example, if a client’s collage contains mainly pictures of the ocean, Sawyer will ask how much time the client is spending near the beach or water. If the client says only once or twice a month, Sawyer will recommend increasing the time that the client engages in activities that will replenish them. For example, the client could go for regular walks on the beach or, if that isn’t feasible, pull up YouTube videos of ocean waves and sounds or simply take a bath to connect with water.

Working with these clients also involves helping them learn to set boundaries and communicate their needs, Sawyer says. She finds that nonviolent communication, an approach developed by psychologist Marshall Rosenberg, is a useful tool for highly sensitive people because it provides them with structure for setting boundaries. This type of communication involves:

  • Observing what does or does not contribute to their well-being
  • Identifying how they feel in relation to what they observed
  • Identifying the needs or values that cause their feelings
  • Making a request to fill that need or have that need met (the concrete actions they would like to see)

Sawyer provides a hypothetical case example. A highly sensitive person is worried about going on vacation with her friends because they are extraverted. The client also fears she will be expected to participate in every activity they have planned and that she won’t get enough downtime. First, Sawyer would help this client identify her needs and preferences for this trip. The client says she would like to have the room farthest away from the common areas because it will provide less stimulation if others stay up late talking. She would also like to tell her friends that she will opt out of an activity to stay in and read.

Next, Sawyer and the client discuss her fear of appearing antisocial if she communicates these needs to her friends. Sawyer uses emotional freedom techniques to help the client ease that fear and calm her nervous system. She asks the client to identify her fear. The client responds, “I feel nervous about talking to my friends.” Sawyer then asks where she feels that fear. The client says, “My stomach feels like it has butterflies.”

After ranking the intensity of the feeling (on a scale from 1 to 10), the client taps different pressure points while repeating the phrase, “Even though I feel nervous about speaking to my friends, I deeply and completely accept myself.” The goal is to have the intensity of her fear drop to a 2 or below.

Next, Sawyer and the client role-play scenarios of the client having this conversation with her friends. For example, she could say, “I’m someone who needs downtime. Would it be OK if I stay in from an outing so I don’t feel so anxious?” or “I’m excited about this trip and love hanging out with you, but I wanted to let you know that I will probably need a couple hours of alone time each day.”

Being a more sensitive counselor

Highly sensitive people “have higher responsivity to counseling interventions,” according to Smith. “Where they have positive fit with the counselor, they do better or they have more of a treatment response, and they seem to get more out of the counseling relationship.”

But how can counselors ensure that they are a good fit for a highly sensitive client? Smith recommends that counselors first think about their own temperament because it will inform any strategy they use. Are they highly sensitive, or are they among the other 80% of the population? At the same time, highly sensitive therapists shouldn’t assume that clients’ experiences are the same as their own, she adds.

“The 80% are very capable of working with highly sensitive people, but they need to be very careful of their own biases because they represent the majority,” Smith continues. “They may jump to a conclusion, or they may have some internalized negative biases of people who are highly sensitive.” If counselors aren’t aware of their internal biases, they risk unintentionally perpetuating some of those negative messages in the therapeutic process, she says. “And the highly sensitive person is coming to counseling because they’re looking for something different than what they’re getting in society.”

The good news is that “many counseling approaches would work well if the counselor is able to adapt it in light of what they know of the client’s high sensitivity,” Smith says. For example, if the counselor stares intently while the client is doing a sand tray intervention, then the client could become overstimulated and have a negative experience, making the intervention less effective, she explains. Instead, the counselor could step back and say, “I’m going to let you do this activity for 10 minutes. I’ll be over here doing my notes.”

Counselors should also think about the way they use language and how the highly sensitive person might perceive it. “The highly sensitive person is probably going to pick up more on nuanced language because, in general,” Smith says, “they’re wired to pick up more subtleties in their environment.” This also includes tone of voice, surroundings in an office, and nonverbal language, she adds.

Bjelland advises counselors to consider the environment in their offices. Is the lighting too bright? Is the client looking into a window? What is the texture of the couch? Does the office have a lot of strong smells such as cleaning products, perfumes or incense?

Smith also cautions counselors to be careful with cognitive behavior therapy. Because highly sensitive people process their environment and emotions deeply, asking them to think about cognitive distortions — the simple ways that the mind convinces a person that something isn’t true — can seem simplistic to them. It can even come across as patronizing to ask a highly sensitive client to reframe a cognition when he or she is having thousands of cognitions on a very deep level, Smith adds. Instead, she suggests saying, “Are these cognitions or depths of processing working well for you, or are these cognitions moving more into rumination?”

Counselors should also be careful when using interventions that might not value the depths of processing because they may unintentionally indicate that there is something wrong with the way the client is processing information, she notes.

Counselors also have the opportunity to reinforce clients’ gift of high sensitivity by validating the strengths and positives of the trait, Smith says. For example, a teacher might feel frustrated because he or she can’t soothe a crying boy. But a highly sensitive child in that same class probably would have noticed that the boy is upset because his crayon rolled under his desk, or the highly sensitive child might even notice the crayon rolling under the desk before the other child does and could grab it and prevent the boy from getting upset in the first place.

Thus, working with highly sensitive people can have far-reaching effects. As Bjelland points out, “You’re really creating a domino impact across the globe when you help a highly sensitive person lift off that layer of overwhelm and help them access those gifts and teach them how to care for their sensitive system because when they are thriving, they go out and help people and make a difference in the world. It’s just who they are.”

 

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The highly sensitive therapist

Many professional counselors don’t just treat highly sensitive clients — they have the sensory processing sensitivity trait themselves. Find out how they manage the benefits and challenges of this trait in the article “Advice for the highly sensitive therapist,” available exclusively at CT Online.

 

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

 

Letters to the editor: ct@counseling.org

 

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

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.”

 

 

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

Letters to the editor: ct@counseling.org

 

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

Study: Genetic wiring as a ‘morning person’ associated with better mental health

By Bethany Bray February 11, 2019

Are you a morning person or a night owl?
Most people consider themselves to be one or the other, with a natural inclination for productivity either in the morning or after sunset.

Not only are these tendencies wired into our genes, but they have a correlation to mental well-being, according to a study published Jan. 29 in the journal Nature. A cohort of researchers found that the genetic tendency toward being a morning person is “positively correlated with well-being” and less associated with depression and schizophrenia.

“There are clear epidemiological associations reported in the literature between mental health traits and chronotype [a person’s ‘circadian preference,’ or tendency toward rising early or staying up late], with mental health disorders typically being overrepresented in evening types. … We show that being a morning person is causally associated with better mental health but does not affect body mass index (BMI) or risk of Type 2 diabetes,” the researchers wrote.

A person’s tendency toward what the researchers refer to as “morningness” is wired into the genes that regulate our circadian rhythm. In addition to sleep patterns, the body’s circadian rhythm affects hormone levels, body temperature and other processes.

Using data from more than 85,000 people, the researchers found that the sleep timing of those in the top 5 percent of morning persons was an average of 25 minutes earlier than those with the fewest genetic tendencies toward morningness.

The study also highlights the connection, reported by previous research, between schizophrenia and circadian dysregulation and misalignment, as well as the increased frequency of obesity, Type 2 diabetes and depression in people who are night owls.

“One possibility which future studies should investigate is whether circadian misalignment, rather than chronotype itself, is more strongly associated with disease outcomes,” wrote the researchers. “For example, are individuals who are genetically evening people but have to wake early because of work commitments particularly susceptible to obesity and diabetes?”

 

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Read the full study in the journal Nature: nature.com/articles/s41467-018-08259-7

 

From the Australian Broadcasting Corporation: “Early birds have a lower risk of mental illness than night owls, genes show

 

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Related reading from Counseling Today:

 

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

 

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

 

Talking about menopause

By Laurie Meyers January 7, 2019

Sleepless nights. Sudden temperature spikes and night sweats. Fluctuating moods. Brain fog. Sudden hair loss (head). Sudden hair growth (face). Dry skin, leaky bladder, pain during intercourse.

This litany of symptoms may sound like the signs of a mysterious and slightly terrifying disease, but they’re actually all possible side effects of a normal, natural life transition: menopause.

Menopause is an inevitable part of life for women — or, more precisely, people with ovaries — but chances are, many clients who show up to counseling know little about it. “The Change,” as it is sometimes called, isn’t taught in sex education classes and is rarely brought up by doctors. Even friends don’t always tell other friends about it. Unprepared for this disruption that usually coincides with a life stage already known as a major time of transition, clients may turn to counselors for help navigating this natural biological process.

Understanding the process

Therein lies the first lesson: Menopause is part of a process. Menopause refers to a specific point 12 months after a person’s last menstrual cycle. Perimenopause, which can begin up to 10 years before menopause, is the transitional time during which most menopausal symptoms occur. Perimenopause usually begins in a person’s 40s but can start as early as a person’s mid- to late 30s.

“During these years, most women will notice early menopausal symptoms such as hot flushes, night sweats, sleep disturbance, heart palpitations, poor memory and concentration, vaginal dryness and … depression,” says American Counseling Association member Laura Choate, a licensed professional counselor (LPC) who has written extensively about issues that affect women and girls.

According to the National Institutes of Health, other perimenopausal symptoms include irregular menstrual periods, incontinence, general moodiness and loss of sex drive. Some people also experience aches and pains and weight gain, particularly in the abdominal area, although experts are unsure whether these effects are tied directly to perimenopause or are instead caused by aging.

LPC Stacey Greer, whose practice specialties include assisting clients with issues related to perimenopause/menopause, says that many clients show up to her office because they’ve been feeling “off” or “not like themselves.” Some of these clients may even have received a perimenopause diagnosis, but most still are unaware of the symptoms and don’t understand the process, she says.

Both Greer and Choate believe that knowing what to expect in perimenopause can in itself ease some of the discomfort of the transition. Choate notes that for those who are unaware of the signs of perimenopause, many of the symptoms can be alarming. Some clients’ symptoms may be mild, but for others, they are severe and can significantly interfere with clients’ functioning and quality of life, Choate says. She adds that symptoms usually peak about a year before the last menstrual period and begin to ease significantly in the second year of postmenopause.

Is it hot in here?

Knowing what to expect from perimenopause is all well and good, but in this case, forewarned doesn’t mean forearmed. Clients still have to live through the symptoms.

Counselors can help with that. Greer says that charting is an excellent tool. She gives clients a chart listing perimenopausal symptoms and asks them to note all the ones that they experience over the course of a month. This allows her to identify and focus on a client’s specific problems.

Hot flashes, night sweats and trouble sleeping are some of the most common complaints. Choate says research has shown that cognitive behavior therapy (CBT) can help with hot flashes and night sweats. She recommends the techniques contained in Managing Hot Flushes With Group Cognitive Behavioral Therapy: An Evidence-Based Treatment Manual for Health Professionals by Myra Hunter and Melanie Smith. The book highlights the importance of identifying and reframing thoughts that occur during a hot flash.

When hit with a hot flash, instead of thinking, “Not other one!” or “I am going to pass out” or “This will never end,” clients can tell themselves, “It will pass” or “Menopause is a normal part of life” or “The flashes will gradually go away over time,” Choate explains.

“In addition to changing self-talk, it is helpful to have an attitude of calm acceptance, mindfully accepting the hot flash instead of trying to push it away or become upset by it,” she says. “There is evidence that mindful acceptance and allowing the flash to ‘fall over you’ helps women cope more effectively. Also, using paced breathing to elicit the relaxation response helps women cope as they focus on their slowed breathing instead of the discomfort that accompanies a hot flash.”

Many people also experience problems sleeping during perimenopause. According to the National Sleep Foundation (NSF), this is not only because of nighttime hot flashes but because of decreasing levels of progesterone, which promotes sleep. The NSF recommends the following for menopause-related sleep problems:

  • Stay cool. Keep a bowl of ice water and a washcloth near the bed for quick cool-offs when awakened by a hot flash. Also maintain a cool, comfortable bedroom temperature (ideally between 60 and 67 degrees), and keep the room well ventilated.
  • Choose the right bedding. Skip thick, heavy comforters and fleece sheets and go for bedding made from lighter materials, such as breathable and fast-drying cotton. This prevents overheating.
  • Eat soy. Eating soy products such as tofu, soy milk and soybeans may help combat dropping estrogen levels. Soy products contain phytoestrogens, which have weak, estrogen-like effects that may ease hot flashes.
  • Consider a natural remedy. Natural hot-flash helpers include botanicals such as evening primrose and black cohosh. Make sure that clients consult a physician before taking these or any other supplements because they are not regulated and may interfere with other medications.
  • Try acupuncture. This ancient Chinese remedy uses tiny needles to unblock energy points in the body and may help balance hormone levels to ease hot flashes and trigger the release of more endorphins to offset mood swings.
  • Balance hormones. Clients should consult a physician for sleep problems that last for more than a few weeks. A physician might recommend hormone replacement therapy (HRT), which helps stabilize decreasing hormone levels and lessen the severity of hot flashes. Other medication options such as low-dose antidepressants and even some blood pressure drugs have also been shown to alleviate menopausal symptoms.

Good sleep hygiene habits are also important. The NSF recommends the following:

  • Get earplugs or a sound conditioner to maintain a quiet environment. Extraneous noise in the bedroom can disrupt sleep.
  • Keep overhead lights and lamps in the home dim (or turn off as many as possible) in the 30 to 60 minutes before going to bed.
  • Position the alarm clock so that it’s difficult to see from bed. Watching the seconds and minutes of a clock tick on and on while trying to fall asleep can increase stress levels, making it harder to get back to sleep when awakened.
  • Keep a consistent sleep schedule. Going to bed and waking up at the same time every day — even on the weekends — reinforces the natural sleep-wake cycle in the body.
  • Develop a bedtime routine. Running through the same set of habits at night helps the body recognize that it is time to unwind.
  • Stay away from stimulants such as nicotine and caffeine at night. Avoid drinking tea or coffee, eating chocolate or using anything containing tobacco or nicotine for four to six hours before bedtime. Alcohol can also disrupt sleep, so avoid more than a single glass of liquor, beer or wine in the evening.
  • Get regular exercise, but not too close to bedtime.

Greer also recommends relaxation techniques. She works with clients to help them focus on the things they can control and let go of the things they cannot control.

Many people find significant relief from hot flashes, sleep problems and mood disturbances by taking HRT or antidepressants, but clients often need help sorting through their options, Greer says. It’s not uncommon for clients to come to counseling with a whole sheaf of information from their OB-GYN, much of which can be difficult to understand. Greer helps clients navigate the material and identify any follow-up questions they have for their physicians. “This can help them feel more empowered and have a voice in their treatment,” she says.

“Speaking to a trusted medical and mental health professional is important at this time,” says Joanna Ford, an LPC whose practice specialties include assisting clients with issues related to menopause and perimenopause. If her clients don’t already have a physician, she suggests that they ask family members and friends or even consult social media for recommendations. In fact, some of Ford’s clients have created circles on social media that offer recommendations on physicians and treating menstrual issues.

Depression risk

Choate, who is currently writing a book on depression in women across the life span, says that depression is a common perimenopausal symptom. “There is an increase in depressive symptoms, first-time episodes of major depressive disorder (MDD) and … risk of recurrence of MDD in women who have a history of MDD,” she says. “Symptoms of depression occur at a 40 percent greater rate [among perimenopausal women] than in the general population, and the prevalence of depression increases 2-14 times in women during perimenopause versus the premenopausal years.”

Interestingly, perimenopausal depression presents slightly differently than depression as defined in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders. In perimenopausal depression, clients are more likely to be irritable or hostile, have mood lability or anhedonia, and have a less depressed mood than is commonly seen in MDD, Choate explains. “Therefore, without a predominantly depressed mood, depression during the transition can be overlooked or misdiagnosed,” she says.

“Counselors can help women focus on self-compassion and self-care during this time, as studies show that there is an increase in negative life events for midlife women compared to other times in their lives,” Choate continues. “This could include children leaving home, caring for aging parents, the death of parents, personal illness, divorce or separation, [and] loss of social or financial support. With the increase in stressful life events, paired with the biological changes of perimenopause, women are more likely to experience distress.”

But all hope is not lost, Choate says. “I think it is helpful to be aware of studies that indicate that while women do experience a decrease in their mental health during these years, recent longitudinal studies show that depressive symptoms decrease as women age out of the perimenopausal years and enter their late 50s, 60s and 70s,” she says. “It is helpful to view this time as a window of vulnerability that does dissipate as women age and as they learn to view mid- to later life as a time of renewal and vitality.”

Sense of self and sexuality

It is not uncommon to feel grief about the menopausal transition. Greer says that some of her clients describe feeling “old” and struggle with their identity as women. “I try to help them work through the grieving process and work toward an acceptance of what is happening to their body,” she says. “It [the transition] does not change who they are, just how they see themselves.”

It isn’t difficult to understand why perimenopausal women feel old. As Choate notes, in Western cultures, youth is viewed as highly desirable, particularly for women, who continually receive the message that signs of aging should be avoided and obscured as much — and as long — as possible.

“The anti-aging industry is designed to perpetuate the myth of eternal beauty — that women can and should maintain a youthful, thin appearance regardless of their age,” Choate says. “The myth implies that women should exert the energy needed to conceal signs of aging, and if they don’t, then they are to blame.”

Women are socialized to prevent or repair skin changes such as wrinkling, sagging and age spots, all of which are natural signs of the aging process. Thinning and graying hair and weight gain are other results of aging that are considered undesirable, Choate notes.

Women “are taught that as they lose their youth, they will also lose their physical beauty, their sexual appeal, their fertility and their overall use to society,” she says. “In contrast, in cultures in which older age is revered, women report fewer symptoms during the menopausal transition. Cross-cultural studies show us that when older women are valued for their wisdom and contributions, they have more positive expectations about aging and menopause, and they also experience few menopausal symptoms. The message from these cross-cultural studies is that when women welcome aging as a natural process, not a disease, and accept naturally occurring changes to their weight, shape and appearance, they are less likely to experience negative symptoms associated with menopause.”

Women may know all of this intellectually, but the societal message is hard to ignore: Youth = beauty = power. Even women who habitually kept these weapons sheathed may feel the shift as they enter the perimenopausal transition.

“Body issues are important to address during this transition time,” emphasizes Ford, a member of ACA. “Aging is part of every life. The culture that we are surrounded by may impact our image of ourselves and our self-value. If we can increase our awareness about how we speak to ourselves about our bodies, it is possible we can accept the changes instead of fighting them.

“People may feel invisible before entering perimenopause, and it can increase feelings of depression and isolation. It is imperative to find a support system that encourages an individual’s values based on a variety of things, such as personal interests, skills, spiritual or religious beliefs, occupation, artistic or creative pursuits or any topic people can connect through.”

Body image issues can become part and parcel of the sexual changes that accompany perimenopause. “Menopause is reached upon the cessation of a woman’s menstrual cycles for 12 consecutive months. This means that menopause culminates in the loss of fertility,” Choate says. “For many women, this is a difficult role transition, particularly if they have based their identity upon a youthful appearance, which is often associated with fertility. For other women, the end of the childbearing years is a welcome change, as they become free from monthly menstrual cycles and also gain freedom from the need for birth control and other pregnancy concerns. They may experience negative biological sexual changes but may be more motivated to seek treatment for these changes as they begin to explore their sexuality apart from its association with childbearing.”

“Women often report a decrease in libido during this time,” Choate continues. “Some of this is due to physical factors — pain during intercourse, vaginal dryness — and some is due to psychological factors, including poor body image, beliefs and expectations about aging and sexuality, stress, fatigue from night sweats, and sleep disruption.”

Estrogen replacement therapies can help with many of the physical factors, but addressing the psychological factors is equally important.

“CBT is also helpful in examining a woman’s expectations for menopause, aging and her sexuality now that her sexuality is no longer linked to fertility and youth,” Choate says. “She might need to change her beliefs about women and aging, viewing menopause as a natural process that occurs to all women but does not indicate a disease, nor does it necessitate a view of herself as an aging, asexual woman. She might benefit from discussing her concerns with her partner to clear up any miscommunication about her partner’s expectations or attitudes toward the changes that are occurring in her body.”

It is essential — but sometimes difficult — to talk about those negative biological sexual changes, Ford notes. “Testosterone and estrogen levels are decreasing at this time and can lead to a change in libido or discomfort during intercourse,” she explains. “I do think people have to ‘re-envision’ their sexuality because hormonal changes are always happening.”

Of course, sex does not mean just intercourse, Ford continues. Embracing different ways of sexual expression can be helpful if intercourse becomes painful. People for whom intercourse is painful may also want to consult their physicians about lubrication or hormonal therapies, she says, adding that she recommends clients read The V Book: A Doctor’s Guide to Complete Vulvovaginal Health by Elizabeth G. Stewart and Paula Spencer.

Ultimately, counselors can help clients see not just the losses associated with menopause but also the opportunities.

“Now that you are entering a new life stage, what new opportunities do you want to seek out for yourself?” Choate asks. “What can you explore and enjoy during this next life phase? Research shows that while women do experience increased unhappiness during their early 50s, longitudinal studies show that they are happier than ever in their mid-50s and into their 70s and benefit from decreased caregiving and work responsibilities in their later years.”

Greer reassures clients that even though the menopausal process may sometimes seem as if it will go on forever, the stage is temporary. “There is life after menopause,” she emphasizes.

 

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

Letters to the editor: ct@counseling.org

 

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