Tag Archives: teenager

Counseling outside the box

By Bethany Bray February 25, 2021

Clients bring an unending range of presenting issues, personalities, life histories and challenges into counseling. Fortunately, counselors also have an infinite supply of tools for forging therapeutic bonds, meeting clients’ needs and helping clients tell their stories.

Counselors need only flex their creative muscles to find approaches that can bolster trust with clients and speak to each person’s unique life experiences and worldview. Exploring a client’s interest in skydiving as a metaphor for self-awareness and trust? Discussing a favorite dish or recipe as a prompt to get a client talking about family-of-origin issues? Assigning a client to play video games online with peers as a first step toward addressing social anxiety? The sky’s the limit.

Counseling Today contacted several counselors who are using interesting, fresh or different approaches to help their clients and students. We hope that you will be inspired by their ideas and possibly use them as a jumping-off point to think outside the box in your own work.

Sparking connection with photos

As the adage goes, a picture is worth a thousand words.

American Counseling Association members Brandee Appling and Malti Tuttle believe the truth of this saying holds up even in counseling settings, especially in the age of smartphones, when photography is ubiquitous. Why not leverage that by asking clients to bring photos and images into sessions, they reasoned. Prompts such as “bring in an image that represents you feeling happy” or “bring in an image that represents your family” can be eye-opening for clients and clinicians alike, Appling and Tuttle say.

The duo, former school counselors who met while working as co-coordinators of the school counseling program at Auburn University, have found that “phototherapy” can encourage dialogue and boost empathy and connection in counseling. This can be especially true in group settings, with child and adolescent clients, and with individuals who struggle with speech or whose primary language is not the same as the counselor’s.

Photos and images introduce “another mode of communication” in counseling, says Tuttle, a licensed professional counselor (LPC) who is an assistant professor and school counseling program coordinator at Auburn.

“Photographs can bring insights into someone’s life that we might miss when talking — things that the client can’t verbally express or doesn’t think to,” adds Appling, an LPC and approved clinical supervisor who is now an assistant professor in the Department of Counseling and Human Development Services at the University of Georgia. “It helps to break down walls [in session] and makes it easier for the client to talk about something that’s concrete rather than [topics] that are in the air, so to speak.”

When Tuttle and Appling have used this approach in school settings, students have often been able to display photos on their cellphones. If students don’t have access to a cellphone, they may be able to check out digital cameras from the school, or the exercise can be widened to include printed images such as postcards or magazine clippings, the counselors say.

The counselor’s role is to prompt conversation by asking questions about the client’s image and then allowing the client to reflect and speak. The counselor should never try to interpret the image or impose their feelings about it, Appling stresses.

“This is not to be used to diagnose [clients]. This is not meant to be a stand-alone tool but part of a range of counseling tools,” Appling notes. “It’s one thing that we would use, but it’s not the only thing we would use. It should be part of the therapeutic process, one tool to use in an interrelated system.”

In group settings, an assignment to bring in an image that “represents you” can help participants get to know one another, build connection and create a sense of belonging, Tuttle says. Asking group members to explain why they chose their image can prompt meaning-making, empathy and recognition of others’ viewpoints and perspectives. It can also provide the group leader a glimpse into each group member’s personality and emotions.

The exercise “builds a sense of universality and connection with one another, [prompting] conversations that might not happen organically,” Tuttle adds.

She suggests spurring dialogue in sessions (whether individual or group) by asking open-ended questions such as:

  • Why did you choose to bring this particular photo?
  • What meaning does it hold for you?
  • What would you title this photo, and why?

Appling has used this approach with a group she ran for students who were going through family transitions (e.g., divorce, a death in the family, living in foster care). When asked to share an image that represented the changes they were going through, one student brought in a photo they had taken of a unique seashell.

The seashell “was a representation, for them, of where they had been,” Appling recalls. “It looked very different than any other seashell that I had ever seen, and I initially didn’t recognize the image as a seashell. We talked about how water had changed it and eroded it. The seashell represented [the student] but also the growth and change they were experiencing.”

This intervention can also be flipped, with the counselor bringing in a photo for clients and students to discuss. When presenting on this intervention at conferences and trainings, Appling and Tuttle use an image of an aging set of concrete steps with vegetation growing through the cracks. They ask participants:

  • What do you think this image means?
  • What emotions does it elicit?
  • What does this photo remind you of in your own life?

Despite being shown the same image, participants typically share a wide range of thoughts, reactions and associations regarding the picture, Tuttle and Appling say. Some people see resiliency and growth in the vegetation, whereas others see decay and despair in the cracked steps.

“It’s really interesting to be able to see the perspective of each participant,” Appling says. “It’s a lesson that we all see things very, very differently and that it depends on the things we have been through, our different lenses. It’s a lesson that we all bring different experiences and viewpoints.”

 

Walking (and running) the walk

Counselors can use a seemingly unlimited number of running-related metaphors to encourage clients: It’s a marathon, not a sprint. Keep putting one foot in front of the other. Focus on the mile, not the marathon. You have to learn to walk before you can run.

But for Natae Feenstra, an LPC with a private practice in Smyrna, Tennessee, this approach goes beyond the metaphorical. An experienced runner who has completed multiple marathons, she sometimes conducts outdoor counseling sessions with clients as they run and talk, side by side. As a counselor who specializes in “running therapy,” Feenstra offers running sessions for clients who are comfortable with and interested in donning their sneakers and hitting the trail with her.

“For the client, it’s first and foremost a counseling session,” says Feenstra, who is working on a dissertation on running as a therapeutic treatment for trauma as part of a doctorate in counselor education and supervision through the University of the Cumberlands in Kentucky. “A goal to get to a certain number of miles is never part of a client’s treatment plan. The goal is improvement of mental health, and running is a tool for that.”

Counselors have long known the benefits that movement and exercise can have on mental health, including stimulating the release of endorphins, dopamine and other brain chemicals. Engaging in movement and exercise also offers opportunities for processing thoughts and mindfully focusing on one’s breath and stride.

“Natural bilateral stimulation — that’s all that running is. Rhythmic movement of large muscle groups, and we know that can bring amazing benefits to our brain,” explains Feenstra, a former school counselor who recently transitioned into private practice. Running therapy also offers the built-in ecotherapy component of enjoying sunlight, fresh air and views of nature as she and the client run and talk, she adds.

Feenstra’s approach is individualized. If a prospective client requests running sessions, Feenstra agrees only after having at least one consultation to get to know the client and their presenting concerns and determining whether the approach would be a good fit. She also offers walking and walk/run sessions, as well as traditional, stationary counseling sessions.

During the COVID-19 pandemic, Feenstra is conducting all of her traditional counseling sessions via telebehavioral health. She continues to offer in-person running therapy for clients who are comfortable doing that, while following health guidelines concerning physical distancing as much as possible.

Above all, she suggests running only if the client is comfortable with it. She points out that clients don’t need to be experienced runners to engage in this approach. She modifies each session to the client’s ability and comfort level. “It’s never about the pace or distance of the run. It’s about the movement, going alongside the therapeutic conversation,” says Feenstra, a member of ACA.

Feenstra has seen significant improvement in clients presenting with anxiety and depression who engage in running. Her clients have also self-reported boosts to their self-esteem, self-efficacy and overall wellness.

In addition to the mental health benefits that running provides on it own, these mobile sessions can help strengthen the counselor-client bond and support clients who might otherwise struggle to open up in a more traditional therapy setting, says Feenstra, who is also a certified running coach with the Road Runners Club of America. “Some people are intimidated by eye contact or other aspects of face-to-face sessions, or being in an office with a power differential. For some people, [running during counseling] can help them speak more freely,” Feenstra says.

This was recently the case for an adult male client on Feenstra’s caseload who presented with severe depression and anxiety. During the COVID-19 pandemic, his condition had worsened to the point that he was no longer leaving home.

When Feenstra and the client began meeting, counseling sessions were the only time the man ventured out. They eventually transitioned to mobile sessions, beginning with a walk/run mix to fit the man’s comfort level. Within a few sessions, his anxiety and depression had lessened so that he was leaving his house more frequently and beginning to reengage in hobbies and activities that he had enjoyed previously.

“The platform of running therapy was what prompted him to leave the comfort zone of his house. A telehealth platform would not have made him leave his house, and he was not interested in pursuing [therapy in] an office environment,” Feenstra says. “In this case, the running therapy was what helped him pursue counseling services. I think it was the running piece that was intriguing [to him], and it was so helpful to get him outside to conquer his anxiety.”

Running therapy “is not a miracle treatment, of course, but there are cases where it can make a difference, just like any therapy,” she adds. Running therapy, pioneered by American psychiatrist Thaddeus Kostrubala, has been around since the 1970s, she notes.

For running sessions, Feenstra meets the client in a park, on a trail or in another public place that she is familiar with or has checked out ahead of time. She begins by warming up with the client and chatting as they stretch. After completing a run or walk, they finish by cooling down and reflecting on the session together.

Feenstra acknowledges the potential lack of confidentiality when holding counseling sessions in a public place. She addresses this with her clients ahead of time, both with detailed language in her informed consent forms and verbally, explaining that they can pause their conversation whenever another person is within earshot.

“I let the client dictate,” she says. “I let them know that [they] can choose to lower their voice, stop talking or continue talking if they are comfortable.”

While many counselors may not be runners themselves, they could have clients who enjoy running. Practitioners don’t have to offer running therapy to leverage running’s benefits for their clients, Feenstra points out. She sometimes incorporates running by assigning clients to run outside of session (again, only if they are interested and able) and then uses that to prompt counseling work in their next session together. Running provides an opportunity to relieve stress, tap into the subconscious and process thoughts away from the distractions of life, Feenstra explains.

Clients may find it helpful to keep a journal to record their thoughts, questions and discoveries made while running. This can be used as a self-development tool or as something the client brings into sessions, Feenstra notes.

“Since the run time is often prime time for thinking, clients and counselors can discuss [in sessions afterward] how the run went and what their thought process was like on the run,” Feenstra says. “Also, since running has an innate mindfulness component, this [aspect] can be used as a counseling tool. The counselor might give the client a thought to ponder or a mindfulness activity to meditate on during their run time.”

 

Movies and moral development

One of Justina Wong’s clients had served a long military career as a sniper with a special forces unit. His experiences in service, including multiple deployments overseas, had left him with posttraumatic stress disorder and a relative inability to show or express his emotions. When he did, it often manifested as anger. His relationship with his wife and family was becoming increasingly strained, and one of his children was beginning to fear him.

In counseling, what clicked for this client was Wong’s suggestion that he watch two movies that, on the surface, were geared toward children: Charlotte’s Web and Inside Out. Wong’s client was able to see himself — and many of the emotions he was having trouble identifying and expressing — in the moral arc these movie characters experienced.

“The response that he had was very powerful,” says Wong, who completed an internship at a nonprofit that serves military veterans and their families as part of her master’s in counseling program at the Chicago School of Professional Psychology. As they processed the movies together in session, “We talked about healthy coping skills and unhealthy coping skills. He began to open up more about what he saw and experienced in the military. He had a very hard time differentiating [between] feeling angry and feeling sad, which is common among this population. Feeling angry is accepted, but feeling sad is seen as [a] weakness or being undependable.”

Cinematherapy, or using movie storylines, characters and themes as a therapeutic tool, can be particularly helpful with child or adolescent clients and those who struggle with depression, trauma, loss or social anxiety, Wong says. It’s also useful for individuals who might not respond well to more traditional counseling interventions and those who have trouble opening up to a counselor, she adds.

Clients can observe and learn from movie characters’ struggles, growth and perseverance in the face of challenges throughout their story arcs, explains Wong, a member of ACA. Clients “can feel like they’re not alone because someone else [a movie character] is going through a similar thing. They can see a character’s unhealthy behavior, coping skills and what they did or didn’t do to manage. It can help clients communicate and voice their emotions and understand what their values are.”

A counselor can either assign a client to watch a particular movie (that the practitioner has vetted) outside of session, or the counselor and client can watch film clips together in session. Either way, the important part of the intervention involves the therapeutic discussion afterward, Wong says.

Wong, a recent graduate of the Chicago School, prompts dialogue with open-ended questions. For Inside Out, these include:

  • Which emotions do you consider to be positive, and which do you consider to be negative?
  • Tell me about a time when you suppressed a particular emotion and, as in the movie, your “island” started falling apart.
  • What islands do you have in your life?
  • What role do joy, sadness, anger, fear and disgust have in your life?
  • Describe a time you felt embarrassment, shame or guilt regarding something from your childhood.

Wong stresses that cinematherapy must be individualized when used in counseling. Practitioners should carefully consider whether the approach is a good fit for each specific client and appropriate for their presenting concerns and therapeutic goals. She uses only movies that she is very familiar with and has prescreened. Her list includes About Time (2013), Mulan (1998 animated version), Yes Man (2008), The Lion King (1994 animated version), Eternal Sunshine of the Spotless Mind (2004), Toy Story 3 (2010) and others.

“You really want to do your due diligence and make sure you’re using this intervention to the benefit of the client,” says Wong, a certified trauma professional. “If you don’t, it [watching movies] just becomes a recreational activity.”

The therapy goals of Wong’s veteran client included mending his relationship with his family and being able to have conversations without becoming triggered and angry. As a grown man and hardened military veteran, he initially bristled at the idea of watching children’s movies. But when he began to understand how they could help him strengthen his family relationships, he agreed. He watched Inside Out with his entire family and discussed Wong’s therapeutic questions afterward with his wife.

When Wong suggested he watch Charlotte’s Web, she warned him about the movie’s sad ending because he had never seen it before. Even so, Wong recalls, he was very upset in the following counseling session. As they began discussing the movie, the client realized that he identified with Wilbur’s feelings of isolation and loneliness. The pig’s friendship with the spider, Charlotte, reflected the camaraderie he felt and the bonds he had formed with the soldiers in his unit, some of whom had not made it home alive.

“He put two and two together and understood that when Charlotte dies, she couldn’t return home with Wilbur, and he [the pig] was angry, sad and in despair. [The client] had served in special forces and had lost many friends and was trying to bury and push away his troubles. … After processing it [in therapy], he understood why I chose that movie for him to watch,” Wong says. “The lightbulb turned on for him when Charlotte and Wilbur have a conversation in the movie and she tells the pig that she can’t return home with him.”

Wong talked these issues through with the client, supporting him as he processed, during which he began to show emotion and cry — a major breakthrough for someone who had appeared emotionless and “very by the book” at intake, according to Wong.

The movie discussion spurred the client to open up to Wong. He disclosed that during one of his deployments, several soldiers he was in charge of had died as they worked to secure and occupy an area. The area was eventually retaken by insurgents, and the client wrestled with feeling that his comrades had “died for no reason,” Wong says. He struggled with moral conflict and felt frustrated and betrayed by his commanding officers and the government. “It was powerful progress. He was able to talk about that, which he had never [done] before,” she says.

When used intentionally, cinematherapy can be a powerful tool, Wong notes. She was inspired to explore the approach after hearing Samuel T. Gladding, a past president of ACA and a professor of counseling at Wake Forest University, present on a range of creative interventions, including cinematherapy, at the International Association of Marriage and Family Counselors conference in January 2020. “It’s up to the counselor to be as creative — or not — as they want to be,” Wong says. “I never thought of myself as a creative counselor, but when I heard Dr. Gladding’s presentation … I guess I’m more creative than I thought I was.”

 

Once upon a time

As a doctoral candidate at North Dakota State University, Robert O. Lester recently taught a class on group counseling to first-year, master’s-level counseling students. Most students, Lester notes, came into the class with an innate understanding of empathy, but as the class neared its end, he looked to delve deeper, teaching empathy in an applied manner.

He turned to fairy tales. Lester asked students to write a tale that illustrated some of the challenges they had encountered and the personal growth they had experienced over the span of the class. The assignment had just two requirements: Begin the story with “Once upon a time …” and don’t make fun of any tale shared in class.

The exercise succeeded in opening students’ eyes to a greater understanding of empathy while spurring the growth of their professional identities. It also equipped them with a creative intervention that can be used with clients in counseling sessions. Going through the “imaginative labor” of observing one’s self in unfamiliar places or scenes expands our concept of what is possible, Lester explains.

“Many students began with ‘I don’t have a story to tell,’” says Lester, a school-based counselor and ACA member. “You don’t need to have gone through some great suffering; you just need to be up close to your own desire and belief. It’s the distance of suffering that empathy can’t cross. It was an assignment to bridge the distance between ourselves and others by keeping the desire and suspending the disbelief. It’s about a willingness to let other worlds be possible. This is the initial move of empathy.”

Weaving one’s experiences into a fairy tale can be a helpful exercise for counseling students and clients alike because the stories are compact and give the writer the satisfaction of identifying a coherent story arc and conclusion, even if it’s not a happy one, Lester says.

Writing fairy tales “is expressive, playful and may surprise you. It can loosen the tongue for serious talk. Letting people become a little more enchanted and surprised with themselves would have a lot of possibilities [in counseling]. Then, it would be on the counselor to facilitate a good discussion afterward,” says Lester, who is now living in California and working as a counselor at an alternative-education high school while he completes his doctoral dissertation. “One of my favorite things about this [intervention] is when we surprise ourselves. … It can certainly break some of the narrative ruts we can get into.”

In counseling sessions, prompting clients to express themselves through fairy tales could be a good fit for “any situation where you want someone to begin trying on differences,” Lester says. “Organizing our experiences into an imaginative story — a story where there’s room for enchantment, and the marriage of emotion and imagination — [can be beneficial] for clients who operate with a lot of constraint in their life, either self-imposed or imposed by culture or external forces, especially if they’re having trouble imagining themselves otherwise.”

Fairy tales offer students and clients a chance to cast themselves in new roles, organize their experiences into a sequence, and reflect on the challenges they’ve overcome and how they’ve grown from start to finish, Lester explains. In turn, they gain an appreciation for their belief of what they’re up against and their desire for how they go on.

This benefit was magnified when Lester invited his counseling students to share and discuss their fairy tales in class. This enabled them to see how different each of their journeys were.

“At the deepest level, I was hoping the fairy tale project would be a hermeneutical project [and] part of their professional identity development — marrying your own worldview into the profession [and] taking the feelings of others seriously and compassionately, especially those who don’t experience the world as we do,” Lester says. “They are just beginning in counseling and have to learn to honor others’ worldviews. This fairy tale [assignment] was a compact way to help them begin by rendering their own experiences as unusual and in need of close reading.”

One of Lester’s students wrote an impactful fairytale about a protagonist named Mia. She lived in an idyllic village where everyone knew one another and worked according to their talents — except for Mia, who spent much of her time alone, reading. Although she liked her fellow townspeople, Mia felt something was missing in her own life, Lester says. She harbored an intense curiosity and sense of imagination that many of her neighbors did not share.

Her story took a turn when some creatures from the outlying forest visited her and asked for her help. An ancient well where they lived, deep in the forest, had dried up. The well was the source of the creatures’ magical powers.

Kindhearted Mia knew she had to help and journeyed into the forest, where she found the well in shambles. Her heart broke for the forest creatures, and at a loss for what to do, Mia began to cry. As her tears flowed, they filled and restored the well. Mia’s compassion had saved the day. Not only had she revived the creatures’ source of magic on her quest, she had also discovered her own sense of purpose.

In class discussions afterward, the student who wrote Mia’s tale talked about feeling alienated in the small town where she grew up. Everyone in town seemed to know how they fit into the fabric of the community, but this student was never able to find her niche, Lester says.

Her fairy tale was a beautiful description of this concept. “She [Mia] is looking for a world where her tears have a place and can do something on behalf of others,” Lester explains. This paralleled the student’s own struggle to find her way and cultivate her professional identity.

“We all go through growing up and forming identity, but her fairy tale elevated the experience,” Lester says. “Suddenly, Mia’s tears could do work and were life sustaining. I find that incredibly moving — that language of having permission to cry, because you don’t know what wells your tears might replenish. To me, that’s a whole other order of coming to apply empathy. [Learning empathy] begins with ourselves and becoming empathic with some of the pain and beauty of growing up. … There’s something poetic in that everydayness.”

 

Culinary therapy

Each of the elements in chef Samin Nosrat’s 2017 cookbook, Salt, Fat, Acid, Heat, can be used as therapeutic metaphors in counseling work with clients, suggests Michael Kocet, a professor and chair of the Counselor Education Department at the Chicago School of Professional Psychology.

If a dish doesn’t have enough salt, it can be bland, but if the cook oversalts the dish, it becomes inedible. “One little [extra] pinch of salt can ruin a dish,” Kocet says. “Talk that through with the client: In life, what do you have that’s not enough or too much? What in your life is that extra pinch of salt? Is it unleashing an opinion on a family member? How can we control that?”

Similarly, acid is very powerful and must be wielded correctly, as in ceviche, in which citrus juice is used to cook the dish without heat. Continuing the metaphor, a counselor can ask a client about the “acid” they have in their life. “Maybe their sarcastic humor is biting. Talk about when that can be useful and when it can be hurtful,” advises Kocet, a licensed mental health counselor and approved clinical supervisor who provides pro bono counseling at the Center on Halsted, an LGBTQ community center in Chicago.

Food, eating and cooking are so intertwined in most people’s life histories, perspectives and preferences that they can become beneficial tools when leveraged in counseling, says Kocet, who taught a course on “culinary therapy” when he was a professor at Bridgewater State University in Massachusetts. Although he no longer teaches that class, he continues to weave culinary elements into his work with clients and students in Chicago and has provided workshops and trainings on the topic.

In addition to tapping into a bountiful supply of culinary-related therapeutic metaphors and conversation starters, counselors can consider giving clients the assignment (when appropriate) of cooking a dish at home and debriefing in session afterward. The dish doesn’t need to be anything complicated, Kocet emphasizes. It could be a peanut butter and jelly sandwich or a simple salad, he adds. Cooking or preparing food mindfully, no matter the recipe, can prompt reflection. Tracking experiences in a cooking journal may also benefit clients who respond well to this approach.

“Food is often a binding element,” Kocet explains. “If I have a client who is struggling in a relationship, I might have them cook a recipe that represents their relationship and talk about that [in session afterward]. Or if a client and their partner are from two different cultures, I might have them cook a meal that incorporates elements from their two cultures. … One aspect to [help] forge cultural connection with clients is to discuss food: what they grew up eating and what was ‘celebration’ food. That’s one way to get to know the client a little more. Clients are often really proud of food and cultural traditions, and it’s one way to connect and break down barriers in a counseling setting.”

Assignments for a client to cook with a partner or family member can prompt bonding and offer a fun and creative way to work on healthy behaviors introduced in counseling, Kocet adds. Also, cooking “failures” don’t have to be failures when talked about and learned from in counseling. Perhaps a client forgot an ingredient or strayed from the recipe. How does that parallel the choices made and lessons learned in their life outside of the kitchen?

Even time spent cleaning up and washing dishes after cooking can serve as a mindfulness exercise, Kocet points out. Practitioners could suggest that clients take time to reflect on how they felt stepping outside of their comfort zone to try a new recipe as they clean up the kitchen and feel the dishwater on their hands.

Kocet has developed a culinary version of the genogram mapping tool that he uses with clients to delve into family issues. He keeps a small collection of cooking spices and a sleeve of mini paper cups in his counseling bag. As he begins the exercise, he lines all of the spice containers up on the table and asks the client to select a spice that represents them and other members of their family circle. The client pours a little bit of each person’s spice into a separate cup. Eventually, a constellation of spice-filled cups is displayed in front of them.

Kocet prompts the client to talk through why they chose that particular spice for each person. Cinnamon or red pepper flakes might signify either a warm personality or a hot temper, Kocet points out. The exercise encourages clients to talk through issues related to their own identity and helps the counselor better understand how the person views their family network, Kocet explains. Similarly, questions that invite discussion of traditions and memories surrounding food can encourage clients to reflect and open up, while giving practitioners additional context on clients’ families of origin and related emotions.

Kocet, an ACA member and a past president of the Society for Sexual, Affectional, Intersex and Gender Expansive Identities (SAIGE), a division of ACA, specializes in grief counseling. “If a client is missing someone they lost, such as a grandmother, it can bring comfort to cook a dish that she used to make,” he says. “Cooking uses all the senses — we can connect with loved ones through the tastes and smells [involved] in the act of cooking.”

As with any counseling intervention, practitioners must be mindful of the ethical ramifications of incorporating cooking and culinary elements into therapy and consider whether it is appropriate for each individual client, Kocet stresses. Clinicians should practice caution in using the approach with clients who struggle with disordered eating, and cooking assignments should not be given to clients who have a history of suicidal ideation or self-harm because knives and other equipment could be involved, he says.

Kocet plans to continue exploring the use of culinary elements in counseling and is in the early stages of a research study on therapeutic cooking as a coping tool for the isolation, anxiety and depression people have experienced during the COVID-19 pandemic.

 

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Staying within scope of practice

Practitioners considering the use of nontraditional approaches in client sessions must always keep the profession’s ethical guidelines in mind. Professional counselors’ licensure guidelines and scope of practice vary from state to state. Practitioners must ensure that any approach, whether a widely used talk intervention or one of many complementary methods such as aromatherapy, reiki, yoga, acupuncture and others, fall within their state’s scope of practice regulations before using them with clients or students.

In addition, counselors must consider the potential risks to client welfare, whether the approach is evidence-based (which is called for by the 2014 ACA Code of Ethics), and their own level of competency in using the method.

 

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Contact the counselors interviewed for this article:

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

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

Online role-playing games as group therapy during the COVID-19 pandemic

By Per Eisenman and Ally Bernstein February 18, 2021

During the challenging era of COVID-19, many young people are experiencing the sort of isolation that can interfere with healthy social development. This may be particularly true for young people who were already wrestling with significant mental health challenges before the pandemic. Telehealth group therapy that utilizes role-playing games offers a hopeful modality for facilitating individual growth in a group context.

Setting the stage

When one of us logs in to the Zoom session 10 minutes early, a picture of a cat immediately pops up. Martin has been waiting all morning for the group to start. He appears briefly and shows us his cat, Betty, sitting on his lap, before turning the video off so that only the photo of Betty is visible.

Gradually, everyone else joins and our game begins. Martin is committed to the group; he has never missed a session and is always early. In Dungeons and Dragons and other role-playing games, group members play fantastic adventurers, working together to overcome obstacles and gain rewards. The facilitator narrates a story, and the group members describe how their characters respond.

Martin plays an elf wizard named Sylvan who has a cat (also named Betty) as his magical animal companion. Martin was initially a bit shy but has integrated into the group and participates in collaborative decisions; he also loves to talk about Sylvan’s cat and backstory. Martin joined the group after the COVID-19 stay-at-home order in the spring of 2020, once we moved to a virtual environment. As is the case with some others in the group, this is Martin’s only social contact outside his family.

The therapeutic group allows for a structured social interaction — a place where people can connect, practice social skills, and modulate their inner and outer worlds. Many of the young people we work with experience social anxiety, depression or social skill deficits. The experience of a safe social setting where they can experiment with becoming someone else allows them to develop connections that can be both an antidote to loneliness and an opportunity for growth.

The COVID-19 pandemic has been a time of isolation. Young people especially are having fewer opportunities to develop socially, and schools are not able to provide as many opportunities for social contact. Telehealth group therapy using role-playing games creates opportunities for social connection and resiliency-building that may not be possible in person during the pandemic.

Collaborative creativity

Role-playing games hold a place in the pop-culture imagination as a niche interest, but their popularity has increased in recent years, and therapists have started implementing the games more widely as a group therapy modality for older children and adolescents. In role-playing games, one facilitator describes an imaginary world, and the participants (playing characters) describe their actions in that world. Sometimes success and failure are based on dice rolls, but players’ creativity and collaboration are also key in helping a group achieve its goals within the world. The game has many decision points, and each player can change the course of the story.

Martin’s character, Sylvan, has blasted open treasure chests with fireballs, duped goblins by pretending to be their grandmother, and hatched a dragon egg. Martin’s creativity influenced the world for himself and the other players, creating a new set of circumstances and changing the direction of the story.

During the game, the facilitator sets the stage: “You enter the pirate’s cavern. As you go in, you see a couple of pirates standing guard.”

The group members discuss how they would like to respond. Should they fight the pirates or try to sneak past them?

“Let’s trick them,” Maya suggests enthusiastically. Maya is shy in real life, but in the game, she plays a tough brute who likes smashing down doors. Martin’s character is cunning and enjoys deception. He likes the idea, and they work together to come up with a ruse.

Martin’s character says, “We are poor pirates who have lost our way in the tunnels. Could you tell us the way to the ship?” He rolls the dice to see whether he can convince the pirate guards to let them pass.

Traditionally, role-playing games are played in person, sitting around a table with maps of the adventure setting, rolling dice, and telling the story together. However, it is possible to play the games remotely through videoconferencing and the use of online platforms. In recent years, remote role-playing game use has increased dramatically. The virtual medium confers new benefits during the COVID-19 pandemic and in an era of physical distancing. It translates surprisingly well to a telehealth group therapy experience. Martin, who struggles with social anxiety, told facilitators, “I like playing online better. I can turn off my video.”

Emergence of change

In the many groups we have run with colleagues, we have observed the emergence of group dynamics and group member interactions that have influenced the choices members make and their participation in the group. Some group dynamics become apparent through the group members’ interactions with one another or from the progress of the group over the course of many sessions. Other patterns emerge in the development of individual group members and the impact they have on the group.

We were particularly struck by the memory of Kendra, who had a very clear vision of how she wanted the game to proceed. She wanted to control the narrative so badly that she soon began frustrating the other players.

“Can I roll the dice to persuade Maya that she should give me her gold?” Kendra asked. She prioritized stealing gold or impressing pirates controlled by the game master over helping the other characters.

This led to frustration among the other group members. Some members began to go silent. One spoke out angrily against Kendra, suggesting the group members’ characters fight Kendra’s character. The frustration of the group turned into a discussion, and Kendra ended up changing her character’s behavior entirely, deciding that her character needed to work with the group and eventually save them, sacrificing herself for the greater good.

She said, “I want my character to help the group, but the shift has to make sense for her character arc. She can’t just change overnight.” We had numerous discussions about what it might mean for her character to develop.

We asked the other group members what they valued about the game, and another member said, “Working together as a team.” The emotional message felt palpable. We were thrilled that the adolescent participants were able to lead this discussion themselves and process as a group with only minimal prompting from the adult facilitators.

Role-playing games involve the players describing the actions of their characters, while the game master describes the rest of the world and the people who inhabit it. The world is imaginary, and visual aids are optional. In a therapeutic group, this system allows for group members to explore identity construction and navigate group dynamics. Therapy groups for teens support the essential task of identity development in the context of relationships with peers and adults.

Much like with any good therapeutic group, what happens within the context of the game often reflects the members’ lives out-of-game. When the game master is also a therapist, questions such as “How are you similar or different from your character?” and “Why did your character make that decision?” make the game a clinical experience. The avatar of the character allows each group member a safe distance through which to explore, process, experiment, fail and succeed.

Group process as an adventure

Role-playing games have long been an effective group therapeutic modality, but creating a shared imaginary world presents unique opportunities during the COVID-19 pandemic, when we are unable to safely convene in person.

Every age has different developmental tasks to achieve, and during the pandemic, these tasks have either been interrupted or have required us to make notable changes in how we carry them out. With schools shifting the way education is delivered because of the pandemic, the amount of social interaction has been significantly reduced. On the whole, we are spending more time isolated from others, and young people are having fewer opportunities to develop socially. Role-playing games, a high-interest activity, allow for social experiences to happen through telehealth in a way that might currently be impossible in person.

Role-playing games feature goals, conflict, choices and relationships. Young people can do something together by completing tasks that require creativity and teamwork. Playing every week creates routine and ritual. Having a group means that young people have regular contact with adults and peers outside their immediate family.

Games can be adapted for different age groups and needs. Children and adolescents can develop executive function and practice resiliency. The technology necessary to play the game online can malfunction and lead to frustration, allowing participants to practice patience and engage in troubleshooting. Also, because the games are fun and silly and joyful, the fantasy setting can provide everyone with a much-needed break from the stress and grief of the current world (or a way to process grief and loss, because characters can die too).

This innovative form of group telecounseling provides an opportunity to engage young people who might not otherwise actively participate in a group process. It also provides an opportunity to support the cultivation of interpersonal relationships with group members in serious need of social skill development. Right now, during the pandemic, if we want to offer something that simulates living and striving in close proximity to others, we can. These challenging times call for innovation. Therapy can become exactly what kids need: a safe but exciting place to be challenged to grow. In other words, an adventure.

 

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Related reading, from the CT archives: “The power of virtual group therapy during a time of quarantine

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Per Eisenman (peisenman@csac-vt.org) and Ally Bernstein (abernstein@csac-vt.org) are community mental health counselors in the Youth and Family Services Program at the Counseling Services of Addison County in Middlebury, Vermont. They have been leading therapeutic groups for teenagers using role-playing games since 2015 and 2018, respectively. At the beginning of the COVID-19 pandemic, they transitioned these groups to telehealth.

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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.

DXM: A drug in plain sight

By Emily Weaver, Sharon J. Davis and David Saarnio November 10, 2020

We are writing this article to raise awareness among parents and counselors about a legal and easily accessible drug that is widely used by adolescents to get high: dextromethorphan (DXM). DXM is an ingredient found in certain medications meant to help us get better, so teens frequently abuse this drug without being aware of the potential consequences and dangers. Given the personal insights and experiences we have with the damaging effects of DXM, we are sharing this story in hopes of reaching a larger population and creating more efficient prevention strategies related to teen drug use.

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When co-author Sharon Davis’ son was 17, he began abusing over-the-counter (OTC) cough medicine. He had been using marijuana and K2 (synthetic marijuana) for a few years, but it was Coricidin — a cold medicine marketed as being for people with high blood pressure — that really damaged him.

Sharon’s son became a different person. He had always been a moody kid, but his moodiness turned to anger, mania and psychosis. Over a four-month period, his father and mother took him to the emergency room four times. It wasn’t until he attempted suicide that they really got him the help he needed and found out the full extent of his addiction.

He had been introduced to Coricidin through some friends. Soon he was using 30 pills at a time. Coricidin use led to cocaine use. Cocaine use led to methamphetamine use. Two years later, he is working on recovery, but his mind and mental health will never be the same.

According to the Partnership for Drug-Free Kids, 50% of American teenagers have misused a drug, and drug overdose is the fourth-leading cause of death among teens. Parents, counselors and other adults are well aware of the problem of teen drug use, and the nation’s opioid epidemic has brought the topic of medication misuse to the forefront of public attention. That attention is long overdue. However, that focus also misleads us because other critical concerns are being overlooked.

For example, our society is largely neglecting to talk about the large-scale problem of adolescent misuse of OTC medicine and its potential as a gateway to other drugs. In fact, OTC cough and cold medicine is one of the most popular drugs that youth use to get high. According to the Monitoring the Future survey funded by the National Institute on Drug Abuse, more teens got high from OTC medicine in 2019 than from prescription opioids.

Why OTC?

OTC cough medication is easy for teens to get. In some places, teens can purchase these medications from their local convenience stores. Furthermore, most stores have these medications out on the shelf where they are easy to steal. Teens can also get them from peers and even from parents. Because they don’t necessarily perceive these types of medications as “dangerous,” many parents will store them in an unlocked medicine cabinet, unknowingly allowing their teens easy access to them.

The psychoactive drug in OTC cough and cold medicine is DXM, which falls into a class of drugs known as dissociative hallucinogens. Other drugs in this category include PCP, ketamine and nitrous oxide. The Food and Drug Administration (FDA) approved DXM as a cough suppressant in 1958. It remains legal to buy and use in the U.S. DXM is a safe drug when used as directed, but when used in 10 times or more the recommended dose, it acts as a powerful dissociative, distorting reality. Currently, 85%-90% of OTC cough medications contain this effective antitussive (cough inhibitor). DXM is a synthetic opioid drug, but it activates different opioid receptors in the brain than prescription opioids do.

Teens typically misuse DXM to feel the euphoric, dreamlike experiences and hallucinations it causes. When individuals use DXM to get high, they experience various levels of inebriation, known as plateaus.

There are four plateaus associated with DXM. The first plateau involves mild intoxication and stimulant-like effects. The second plateau features increased intoxication and mild hallucinations. At the third plateau, the user enters a state of altered consciousness with impaired senses and psychosis. The fourth plateau involves a sense of derealization (in which the world appears unreal) and depersonalization (e.g., detachment from the self).

Users describe the higher plateaus as akin to being in other realms or alternate universes. Commonly, users feel an out-of-body sensation, like being transported to another dimension. They lose their sense of self and time. It is common for users to post videos or blogs about their experiences, including what they felt like and what they saw while high. The slang term robo-tripping is how many teens refer to being high on DXM. Slang terms for the drug itself include triple-C’s, robo, skittles, red hots and dex.

Why is DXM problematic?

DXM is a dangerous drug when used outside of therapeutic doses, yet little has been done to curb its misuse among teens. For decades, we have known about the consequences of misusing this drug, including seizures, hyperthermia, tachycardia, psychosis, mania and even death.

The opioid epidemic in this country is a national crisis. It is worthy of public attention and government funding to address. At the same time, DXM misuse among teens is also startling, and yet it is rarely highlighted. This drug is more popular than opioids among young people, and it is legal, inexpensive and easy to get.

It is imperative that prevention efforts and policies address this problem. For example, laws similar to those passed in 2005 that required pharmacies to move the popular methamphetamine-making drug pseudoephedrine behind the counter could make DXM less readily available. Some states already require purchasers of OTC cough and cold medications containing DXM to present an ID proving they are 18 or older. We believe this should become mandatory nationwide and that sellers of these drugs should be held accountable.

Furthermore, mass awareness campaigns targeting parents, teachers, law enforcement and counselors need to remind adults of the dangers of these drugs, whereas prevention programs for children and teens should increase their focus on the dangers of OTC medications. National campaigns and policy changes are called for, but these alone will not likely be enough to cause real change. True prevention efforts require work on multiple levels — from the policymakers in Washington to counselors and parents in local communities. Each of us has a part to play, and each can make a difference.

Where do teens hear about DXM?

In today’s era of prolific internet and social media use, teens have more access to the world than ever before. In past decades, peer pressure to use drugs was a huge concern. It was thought that susceptible teens would be influenced by their peers in the neighborhood and at school. This peer pressure occurred face to face.

Today’s teens still confront in-person peer pressure, but they now also face this pressure virtually. Peer influence can come not just from the local teens at school but from millions of teens across the world online. Many teens access the internet and find out about drugs of abuse, including how to get high on OTC cough and cold medications.

A quick search of popular sites such as YouTube can lead teens to videos that either warn of the dangers of DXM or encourage users to experience the high from it. Unfortunately, many websites include dosing recommendations and “tripping” suggestions for having a better experience of getting high.

For example, Reddit, one of the most popular social media sites around the world, has an estimated 430 million active users. Reddit consists of threads that allow its users to post about certain subjects and topics. These threads are like cybercommunities made up of members who hold similar interests. One of these threads, called “r/DXM,” has more than 31,500 users. This thread allows people a place to describe their DXM highs and the side effects. It also provides advice on how to minimize certain side effects such as nausea.

Other websites and cybercommunities such as Dextroverse.org and the Vaults of Erowid provide teens outlets to post about their DXM highs and get advice from other users on how to use the drug. The site DexCalc.com allows users to enter their weights and get a recommended dose for the “plateau” of high they want to achieve. Although many of these websites claim that their purpose is “harm reduction,” teens typically use these sites for suggestions and advice on the “safest” using pleasures. All of these websites are accessible to teens, and all of them are free to use.

Prevention efforts

Fifteen years ago, the FDA issued warning labels on OTC cough and cold medications aimed at making parents aware of the dangers of medicine abuse by teens. The Stop Medicine Abuse campaign launched nationwide in 2004, but clearly that campaign was not successful. More needs to be done to dissuade youth from abusing OTC drugs.

As counselors, we need to step to the front lines of true preventive efforts. This means that we need to know more about DXM (and other OTC medications), the reasons teens are using it, the ways teens are getting it and the most effective methods to prevent its misuse.

Getting parents involved is a good first step. Parents must know what to look for and how to talk to their teens about OTC drugs. Counselors need to get the message out to parents to be realistic and truthful when educating teens about DXM. Scare tactics do not work for many teens; in fact, they may make teens more curious about experiencing the outcomes for themselves. A better approach for prevention may be for parents, family members and other adults to increase the quality of their connection to and communication with youth.

Research shows that establishing consistent messages against drug misuse and having clear boundaries early on can be among the best prevention efforts for teen drug use. Simple steps, such as hiding medications and taking inventory, can also be effective. Most parents want to trust their teens, but having medications that contain DXM where teens can access them is not wise, and many parents are not aware of the dangers of DXM medications. OTC cough and cold medicine should be as securely stored as opioid prescriptions.

In addition, parents need to know what sites their teens are accessing online. A parallel line of defense involves checking browser histories and having clear rules about what teens can access online. Drug use is a leading cause of death among teens (resulting in more than 5,000 deaths per year according to figures from the National Institute on Drug Abuse). Parents wouldn’t want their teens searching for firearms or lethal poisons online, and no parent should want their teen searching for how to get high from DXM. Parents may not be comfortable with this advice. After all, it may feel like snooping, and teens are likely to resist as well. Even so, what teens access online can be one of the biggest telltale signs of drug use.

Establishing rules for computer/internet usage (e.g., allowing a teen to use the internet for two hours a day after completing homework), installing a firewall and setting locks or passwords for downloads can all be safety measures that contribute to prevention or, when needed, intervention. The earlier that parents establish household internet rules, the better. Proactive planning and putting rules in place before children reach their teen years may prove much easier than trying to establish new rules once teens are in late adolescence.

Talking to teens about drug use is often uncomfortable for parents. Many parents do not know where to begin. Some parents are worried that talking about drugs will increase their children’s curiosity about using. Other parents simply find the topic embarrassing or awkward. As counselors, we need to help parents develop communication skills with their children and teens, but especially starting in middle childhood. Counselors can provide parents with resources for where to find information about drugs of abuse, and we can intervene if a teen has already started using. It is almost a certainty that teens talk to other teens about getting high on OTC cough and cold medication. As counselors, we need to encourage parents to talk to their children about choosing not to get high on it.

If Sharon Davis, as both a counselor and parent, had recognized the signs of DXM abuse in her son, he might have gotten help sooner. The message we want parents and counselors to hear is that DXM is one of the most popular drugs for teens, and despite it being legal and easy to get, it is not safe when misused. Sharon was unable to prevent all the damage done to her son, but we hope that her story will help parents of children and teens across the country to protect their own sons and daughters.

 

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Emily Weaver is a graduate student in the clinical mental health counseling program at Arkansas State University. She plans to graduate in the spring, become a licensed professional counselor and pursue a career in addictions counseling. Contact her at emily.weaver@smail.astate.edu.

Sharon J. Davis is a professor at Arkansas State University and a certified rehabilitation counselor. Contact her at sharondavis@astate.edu.

David Saarnio is a professor of psychology at Arkansas State University with a specialty in developmental psychology.

 

Counseling Today reviews unsolicited articles written by American Counseling Association members. To access writing guidelines and tips for having an article accepted for publication, go to ct.counseling.org/feedback.

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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.

For such a time as this: Plan of action for young adults, adolescents and parents

By Esther Scott June 22, 2020

[Editor’s note: This is the third of four articles in a series on action plans for different areas of life during the COVID-19 pandemic.]

To young adults, the risk of contracting the coronavirus or suffering a negative outcome may feel remote. Research studies show that when young people talk about risk reduction, they tend to be referring to reducing social or reputational risks. As a young adult, you may be in the same boat. While the individual risks of COVID-19 may seem low for young people, it is worth stating that becoming infectious could worsen the health and financial security of your community and make it much harder for you to find work, especially if you are just graduating.

Remembering that your youth and health give you “superhero” powers will help you take a more active role in this crisis to protect yourself and those you love. As the line from the Spider-Man comics and movies reminds us, “With great power comes great responsibility.” You have the power of good health, and it is your responsibility to help solve the problem by protecting yourself and others.

Here is a plan of action for young adults, adolescents and their parents.

 

1) Obtain reliable information.

A deep understanding of how people view risk is crucial to stopping the spread of disease. Gathering a similar understanding of COVID-19 can help young people to participate willingly instead of resenting authority. It is important that you see breaking physical distancing guidelines as being risky not only for yourself and those you love, but risky for your entire community.

The same is true when it comes to understanding your economic risks. Analysts believe that young workers and new grads may be hit harder because they tend to work in the food, retail and hospitality industries — places that are experiencing harsher impacts as consumers stay home more. Obtaining reliable information will help you navigate the expected upcoming changes.

2) Control peer pressure. Prioritize safety over reputation.

One obvious reason for the prioritization of social reputation over health risk is peer pressure and the need to fit in socially. In the wake of COVID-19, there were numerous stories in the media highlighting young people who continued to gather despite social distancing guidelines. There were also reports of young adults violating shelter-in-place and social distancing orders to meet lovers and potential hookups because they felt pressured by friends to do so.

One way to evade social pressure is to plan your response ahead of time. Hosting remote meetings and parties could be one such response. With the rise of social media, distant hangouts are trending.

 

Plan of action for students and adolescents

In this difficult situation, it is best to look at the positive side: We have unbelievably valuable time to spend at home. This unprecedented situation that we are experiencing affects everyone. Adolescents too can learn to manage what they can control so that they emerge from this stronger. We can use this crisis to help them grow as resilient, autonomous human beings. Here is plan of action that can help students and adolescents make the most of this situation.

1) Keep a structured routine — a time for everything.

It is particularly important to keep a predictable routine. Develop a schedule that includes activities such as family sports, reading books, and collaborating with the rest of the family. It is important that students, especially teenagers, spend time in productive physical activities. Go out and throw the ball, shoot some baskets, go for a walk around the block or simply do some jumping jacks.

2) Continue education by reading and writing.

Two other important activities for students and adolescents during this crisis are reading books and writing thoughts. This time at home is the perfect opportunity to dedicate yourself to reading books and stories that have been on the shelf for a while. If possible, we recommend reading together as a family, including reflecting on the content of the story or answering questions that come up after reading it.

Writing thoughts or a diary with the events of the day or a gratitude journal about things you enjoy will continue to help you put these circumstances in perspective. If you graduated from high school or college this year, consider staying in school to pursue the next level of education. It could help you land a higher-paying job in the future.

3) Get involved.

Participating in household chores and taking responsibility for “their things” (their room, their clothes, etc.) is especially motivating for older children and adolescents. Allowing them to collaborate in the kitchen by researching new recipes or cooking (especially when personal assistants such as Google Assistant and Alexa are available for recipes) can also help develop growth and autonomy.

There are various ways that students and adolescents can take their place in this moment in history and make this time more enjoyable. They can write letters to the older adults in their families or communities and show appreciation for health personnel by sending prayers to them and those who are sick. It is good for young people to develop a sense of belonging in their communities and to know that their actions make a difference.

 

Plan of action for parents

Sticking to a routine is essential to keep your sanity (just as it is for your children). Maintaining a schedule can be helpful in creating a bit of normalcy in this unexpected situation and in reducing your anxiety level because your brain will feel in control.

Be a team. Keep it balanced. If you have a partner, try alternating who is looking after the kids or making meals. But most importantly, communicate your needs to your team. Remember that flexibility is key in times of crisis. Be kind to yourself; you are doing the best you can.

Although we have yet to see the full extent of the economic slowdown induced by COVID-19, analysts currently expect that we will recover once the virus is under control. So, hold on.

 

 

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Esther Scott, LPC

Esther Scott is a licensed professional counselor in Arlington, Texas. She is a solution-focused therapist. Her specialties include grief, depression, teaching coping skills and couples counseling. Contact her through her website at positiveactionsinternational.com.

 

 

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

School vaping cultures: Acknowledging the impact of COVID-19

By Zachary Short and Nicole Baliszewski June 4, 2020

This past January, global tobacco conglomerate Altria saw a major drop in its stock value on the New York Stock Exchange, depreciating at a value of almost 40% versus its record-breaking highs in 2017. What caused this sudden dip in one of the biggest-rebounding industries of the 21st century? It would be fair to suggest that the COVID-19 pandemic has caused some major complications for both the traditional and electronic cigarette corporations located across the United States.

As a respiratory-based infectious disease, COVID-19 poses an unparalleled threat to the health and safety of individuals across the age spectrum with significant histories of vaping or smoking. In fact, a recent study in the New England Journal of Medicine found that Chinese patients with a history of smoking were twice as likely to suffer from severe infections associated with diseases such as COVID-19 in comparison with those without any smoking history.

Having always opposed the youth vaping/smoking culture, counselors and community advocates across the nation are currently working to answer a significant question: What actions can we be taking to protect our communities from the combined threat of COVID-19 and recent vaping trends?

The truth is, now is the prime time for considering how we can influence our communities to create better post-quarantine schools for our students.

The loss and revitalization of the smoking industry

Only five years ago, health specialists with the Truth Initiative anti-smoking campaign speculated that the tobacco industry and most of the nation’s smoking addictions would expire with the Generation Z demographic. But vaping, the process of inhaling prepackaged aerosols (also known as vapor), has led to the resurgence of nicotine products within school systems.

Through a combination of peer pressure and social media campaigns, students from all backgrounds have found themselves under the influence of Altria’s newest partner, Juul Labs, maker of the Juul electronic cigarette. Largely as the result of the popularization of this flavored electronic smoking device, the number of high school students who use nicotine products has increased from 3.6 million to 5.4 million in the span of only one year, according to the Centers for Disease Control and Prevention (CDC).

How significant it would be to know that schools were free of the harmful aftereffects of adolescent smoking, leaving school counselors and clinicians available to attend to the important mental health developments that are so essential in our school systems right now. Instead, we find ourselves dealing with another truly concerning issue: According to the Truth Initiative, 1 in every 4 high school students now uses e-cigarettes.

These concerning statistics represent a call for preventative action in middle schools across the nation. A number of schools and organizations have taken such counteractions to trends in vaping by launching interventions such as confiscation, disciplinary action, and even educational programming. But the culture of vaping continues to persist as a significant concern for parents and educators.

The most terrifying thing about the Juul product so far is that it appears to come off as being innocuous to many people. Most students and parents recognize it as the small USB-shaped device that produces fruit-flavored smoke. Very few seem to grasp the long-term consequences of vaping habits. That being said, those consequences might already be here.

The individuals at risk

Based on data collected by the CDC in early March, evidence suggests that COVID-19 poses a serious threat to all individuals ages 65 and older. Fortunately for students under the age of 18, the percentage of those infected and harmed has been relatively low by comparison.

While most parents find some comfort in hearing that the student demographic is the least impacted by the pandemic, the statistics can change drastically if students are part of the vaping culture that is rampant among youth. According to data provided by the CDC for China’s mainland population facing COVID-19, individuals with respiratory issues predominantly associated with even a small history of smoking or vaping have a 6.3% case fatality rate, in contrast to 2.3% overall. Recognizing how exposure to vaping increases a person’s health concerns, imagine the increased risks that our students could face should their still-developing physiques come in contact with both nicotine products and a respiratory infection.

“What they say is about 80% of people feel the flu, but they will be OK. Where we are getting into trouble is that it can lead to severe pulmonary distress,” says Anna Song, an associate professor of health psychology and leader of the Health Behaviors Research Lab at the University of California Merced. “Smoking is a risk factor for having this disease progress, be incredibly severe, and lead to mortality.”

As we know, COVID-19 has posed widespread challenges to the health and lifestyles of the global population. Societal and educational norms have begun to deteriorate, and everyday tasks and responsibilities now come with an unprecedented health risk to individuals and their families. Of great concern to us is that the unattended trends and cultures of our school systems could be having a negative impact on our students right now. To allow these trends to persist beyond this pandemic is to continue putting our students at risk unnecessarily.

A unique opportunity for change

What makes now such an ideal time to invest in removing the harmful vape cultures that continue to linger in our school systems? Students are largely being required to undertake remote learning during this time, and that may continue for many students even as a new school year begins. The changes and circumstances that come with students’ remote learning actually promote our greatest opportunity for the development of an anti-smoking culture.

Society is recognizing that our plans, policies and preparation were inadequate to succeed in the face of an unanticipated global pandemic. Thus, things are beginning to change. Legislation is developing to create preventative actions around practices deemed unhealthy by medical specialists, and educational policy is constantly being reformed to reflect the needs and issues present in our impromptu teaching conditions. If there was ever a time to acknowledge the statistics that point to the harm that nicotine products pose to our adolescents and to advocate for the safety of our children, it is now.

Large systemic changes are challenging and often are out of our hands, but educators and parents currently have the opportunity to make a notable difference in students’ environments. During this time of partial quarantine, most families are now all in one location — the home. Our students currently find themselves in a setting where they are under the watchful eyes of their families and where smoking purchases and practices are essentially impossible.

In addition to that, they are also in a potential learning atmosphere. Through the joint efforts of educators and parents, our youth can be exposed to real educational and intimate conversations regarding the dangerous practices of smoking. These conversations can mean the world to students who currently feel that their futures and health might be dictated by vaping culture.

COVID-19 has had a harsh and unpredictable influence on our way of life, but it also presents us with a rare opportunity to support our students through one of the greatest health issues of their generation. So, making use of the present, it is time that we as a supportive community of counselors consider what we should be doing to help facilitate and emphasize this process of growth for students’ mental and physical health.

Our responsibility to intervene

As of early April, individuals within Rowan University’s Department of Psychology have been conducting their own research to confront the vaping culture that remains prevalent during the COVID-19 pandemic. Their research takes an interesting approach to behavioral analysis with younger age groups, including the development of interesting activities such as mobile- and video game-based interventions that promote smoking abstinence.

Fortunately, this is just the tip of the iceberg when it comes to the collective efforts of universities to combat vaping trends in student populations. Even educational institutions outside of higher education are recognizing the statistically supported danger that vaping is putting our students in when facing the current health pandemic. As a community, it is our collaborative responsibility to provide education and to take the necessary precautions to protect our students’ health. We are just beginning to understand the proper steps to take when working from a remote distance.

Educating the community: Providing knowledge of the increased risks and hazards of smoking behaviors is the first step to reducing nicotine consumption within our school systems. Given the myriad resources available on the consequences of vaping from the CDC, the National Institute on Drug Abuse and even university websites such as Johns Hopkins Medicine, it is the obligation of school counselors and other school personnel to appropriately share this information with our local communities. It is important to remember that this information needs to be given not only to the students we support, but also to our educational partners and to the families who are acting as our immediate support systems in homes at this time.

Promoting real conversations: With the knowledge and statistics being supplied to our students’ homes, it is more important now than ever that school systems promote real conversations with students regarding the present vaping cultures. Whether it is school counselor-to-student or parent-to-student conversations, we need to understand what the student perspectives are when they see products such as Juul in the media while also witnessing terrifying statistics regarding the spread of a global virus.

With those who are currently smoking, it is vital that we understand their concerns and interests so that we can provide them the appropriate support they need. These conversations are the optimal opportunity to promote and communicate resiliency, empathy and community support to our students. And with those who have never touched a vaping device, communicating this information and the associated risks is the best possible preventative action at this time.

Advocating for policies: To reiterate, now is a turbulent time when leaders are reflecting on educational preparations and policy and how they might be applied for future incidents. In addition to redesigning our school’s remote learning policies, we need to be working as a professional community to advocate for anti-vaping policies within our schools. It is essential that school counselors reflect on school policies regarding smoking tolerance, as well as preventative actions to take, so that they can create real opportunities to support student health.

Fortunately, states and health institutions are rallying to create a number of anti-vaping models that can be implemented or referenced by school counselors looking to better their schools. One such model is the Make Smoking History campaign, conducted by the Massachusetts Department of Public Health, to reduce the percentage of vaping disciplinary actions taken in middle school settings. This is the time to ask for and support the voices of the education community to find out what should be done for the development of our educational systems — not just on a school-by-school basis, but from a legislative perspective.

Forming support groups: Finally, acknowledging that this is a difficult time for individuals who have a dependency on smoking tools to which they no longer have easy access, we need to prepare and create remote counseling groups to support them through potential issues such as withdrawal or rehabilitation. A number of counselors may struggle with the concept of remote group counseling, but these students still need emotional and mental health support to cope with their new distancing from vaping. Counselors should utilize the medical resources and personnel within their school districts to support students in their transition to healthier living. Ultimately, it is groups such as these that we should be planning to implement more frequently in our later return to school.

The truth is that in the midst of a global health crisis, most individuals view the issue of vaping in school systems as relatively small. But the fact is that vaping is a real health issue for our youth, and in combination with the threat of COVID-19, it puts our newest generation of students at exceptional risk for loss. In a moment in history when many counselors are at home and wondering what they should be doing to support their students, imagine what significant change could occur if we all directed a portion of our efforts to acknowledging and countering the present vaping culture.

 

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Related reading, from the Counseling Today archives: “Pushing through the vape cloud

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Zachary Short is a master’s counseling in educational settings student at Rowan University. He currently works as a clinical research intern in a high school setting, where his research in student behavioral outcomes is being supported through the Mental Health Grant Demonstration Program. Contact him through LinkedIn: linkedin.com/in/shortzachary/.

Nicole Baliszewski is a master’s counseling in educational settings student at Rowan University. She currently works as a clinical intern in a middle school setting, where she seeks to provide trauma and mental health support to the special education student population. Contact her through LinkedIn: linkedin.com/in/nbaliszewski/.

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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.