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Group Work

Life after traumatic brain injury: Lessons from a support group

By Judy A. Schmidt October 8, 2018

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

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

 

Effects of TBI

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

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

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

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

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

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

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

 

Psychosocial aspects of TBI

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

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

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

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

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

 

Lessons learned

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

 

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

 

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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.

Group counseling with clients receiving medication-assisted treatment for substance use disorders

By Stephanie Maccombs September 6, 2018

Holistic care, or the integration of primary and behavioral health care along with other health care services, is becoming more common. In my experience as a mental health and chemical dependency counselor in an integrated care site, I have come to value the benefits that such wraparound services offer.

I now have the opportunity to consult with primary care providers, medication-assisted treatment providers, dentists, early childhood behavioral health providers and our county’s Women, Infants and Children team about their perspectives and hopes for clients. Every client has a treatment team, and each team member is only a few feet from my office door. I quickly realized the significant positive impact that close-quarters interdisciplinary collaboration has for many clients, and particularly those receiving medication-assisted treatment (MAT) and counseling services for substance use disorders.

MAT is a treatment model that lends itself to the integrated care setting. As described by the Substance Abuse and Mental Health Services Administration (SAMHSA), MAT is the use of prescribed medications with concurrent counseling and behavioral therapies to treat substance use disorders. MAT is used in the treatment of opioid, alcohol and tobacco use disorders. The medications, which are approved by the Food and Drug Administration, normalize brain chemistry to relieve withdrawal symptoms and reduce cravings. MAT is not the substitution of one drug for another. When medications in MAT are used appropriately, they have no adverse effects on a person’s mental or physical functioning.

Medications used in MAT for alcohol use disorder include disulfiram, acamprosate and naltrexone. Those used for tobacco use disorders include bupropion, varenicline and over-the-counter nicotine replacement therapies. Medications used in MAT for opioid use disorders include methadone, buprenorphine and naltrexone — each of which must be dispensed through a SAMHSA-certified provider. Naltrexone is the only medication of the three that does not have the potential to be abused. Federal law mandates that those receiving MAT for opioid use disorder also receive concurrent counseling.

Embracing the advantages of integrated care

The combination of medication and therapy offers a holistic approach to treatment that is easily implemented in integrated care settings. The hope offered by the integration of services is embodied in an extraordinary case involving one of my clients who relapsed and arrived to counseling intoxicated, holding their chest. I was able to immediately consult with the client’s MAT provider, who ruled out the physical causes of chest pain after performing an electrocardiogram. Within 30 minutes, I was able to proceed with de-escalation of the client’s panic attack. The MAT provider educated the client on the next steps for care and on the dangers of using substances while taking MAT medications.

In a nonintegrated site, my only recourse would have been calling an ambulance for the client and a long wait at the hospital emergency room — and possibly a client who discontinued services. It is heartening when I can instead walk a client with symptoms of withdrawal across the hallway to the MAT provider or primary care provider, who can in turn offer targeted expert medical advice and medications to alleviate the symptoms.

Despite the substantial advantages that integrated care offers, however, most mental health and chemical dependency counselors are not adequately trained to provide effective counseling in integrated care settings for substance use disorders. In my experience, clients have better outcomes when receiving counseling services in conjunction with MAT. MAT alone can be effective, but the underlying thoughts and emotions that perpetuate use are not addressed unless concurrent counseling services are offered.

According to SAMHSA’s Treatment Improvement Protocol (TIP) No. 43, counseling for clients in MAT programs:

  • Provides support and guidance
  • Assists with compliance in using medications in MAT appropriately
  • Offers the opportunity to identify additional areas of need
  • May assist with retention in MAT programs
  • Offers motivation to clients

Although individual counseling is valuable, I am focusing on group counseling in this article because it offers similar benefits to individual counseling and is typically more cost-effective. In addition, TIP No. 43 notes that group counseling in MAT programs reduces feelings of isolation, involves feedback and accountability from peers, and enhances social skills training.

Resources for group counseling with MAT clients, or group counseling in integrated care settings, may not be easily accessible to many counselors-in-training or to practicing counselors. My goal is to share tips and resources with mental health and chemical dependency counselors that may be helpful in enhancing group counseling services for clients receiving MAT in integrated care settings. These tips and resources may also be useful to those providing group counseling services to MAT clients in settings that do not offer integrated care.

Tips and resources

1) Holistic education: MAT and integrated care are relatively new concepts for counselors, and we are still adapting. If it is new for us, it is new for our clients too. In the initial sessions of psychoeducational or process groups, the inclusion of education about MAT, the benefits of counseling in conjunction with MAT, and treatment in integrated care settings is essential.

Having access to a range of service providers is a benefit that clients should understand and utilize. Treatment team members can speak to the group about their role in client care and how their role may relate to the counseling group. For example, a dentist might help with appearance and self-esteem issues; an early childhood care provider might help the children of clients process situations arising from parental drug use; a primary care or MAT provider might link the client with hepatitis C treatment in addition to MAT. Such education can answer many questions that the group may have and help clients benefit from quality holistic care.

2) Dual licensure and continuing education: Many chemical dependency counselors refer out to mental health counselors and vice versa. In integrated care, it is ideal for counselors to be dually licensed. Dual licensure and training can assist counselors in identifying and addressing a variety of dynamics that may arise in group counseling with MAT clients.

For example, one client might have major depressive disorder and be using MAT for alcohol recovery, whereas another client might have symptoms of mania and be receiving MAT for opioid recovery. The way that counselors assist these clients may differ based on their knowledge of mental health diagnoses and the substance being used. Furthermore, counselors who are knowledgeable about these differing yet comorbid disorders will be better equipped to provide education to the group about the individualized and shared experiences of each member in recovery.

Some states have a combined mental health and chemical dependency counseling licensure board, whereas others have separate licensing boards. For more information about licensure, contact your state boards. If dual licensure is not plausible or desirable, I strongly recommended seeking continuing education in both mental health and chemical dependency counseling, as well as their relation to MAT.

3) Cognitive behavior therapy (CBT) and solution-focused brief therapy (SFBT) techniques: According to SAMHSA’s webpage about medication and counseling treatment, by definition, MAT includes counseling and behavioral strategies. The combination of MAT with these strategies can successfully treat substance use disorders.

One of SAMHSA’s recommended therapies is CBT, an evidence-based practice that has been shown time and time again to be effective in the treatment of substance use disorders. In an extensive review of the literature about the efficacy of using CBT for substance use disorders, R. Kathryn McHugh, Bridget A. Hearon and Michael W. Otto (2010) outlined a variety of interventions shown to be effective in addressing substance use disorders in both individual and group counseling. Those interventions included motivational interviewing, contingency management, relapse prevention interventions and combined treatment strategies.

Combined treatment refers to the use of CBT alongside pharmacotherapy, which includes MAT. Although some studies the authors reviewed indicated that MAT alone could be effective in treating substance use disorders, others demonstrated that combined treatment was most effective. Given SAMHSA’s recommendation, the literature review and my own personal experience, I believe that CBT may best benefit a group of MAT clients with substance use disorders in an integrated care setting.

Although CBT is suitable, I have learned that integrated care sites are much more fast-paced than the typical behavioral health counseling agency. Primary care and MAT appointments are as short as 15 minutes. In my work with our on-site behavioral health consultant, I noticed her quick and effective use of SFBT with individual clients. Although there is some research discussing the use and efficacy of SFBT in the treatment of substance use disorders, there is little information about using SFBT in groups with MAT clients in integrated care. This is a much-needed area for future research.

4) SAMHSA: SAMHSA has been mentioned various times throughout this article. That is a tribute to the value I place on the agency’s importance and usefulness. SAMHSA, in my opinion, is the best resource for exploring ways to enhance groups for clients receiving MAT. SAMHSA offers educational resources about a variety of substance use disorders; forms of MAT for different substances; comorbidities; and evidence-based behavioral health practices. SAMHSA is up to date, provides a variety of free resources for counselors and other professionals, and also has information about integrated care for professionals and clients.

According to SAMHSA’s TIP No. 43, groups commonly used with MAT clients include psychoeducational, skill development, cognitive behavioral and support groups. Suggested topics for individual counseling with MAT clients, which easily can be translated to group format, include feelings about coping with cravings and a changing lifestyle; how to identify and manage emergencies; creating reasonable goals; reviewing goal progress; processing legal concerns and how to report a problem; and exploring family concerns. Visit SAMHSA’s website (samhsa.gov) to enter a world of helpful information and resources for both personal professional development and client development.

5) Professional counseling organizations: Whereas SAMHSA offers information about substance use disorders, comorbidities, MAT, and individual and group counseling, the counseling profession’s codes of ethics and practice documents are crucial to the ethical provision of group counseling in this challenging field. Among the resources to consider are the 2014 ACA Code of Ethics, the Association for Specialists in Group Work (ASGW) Best Practice Guidelines (which clarify application of the ACA Code of Ethics to the field of group work) and the Association for Lesbian, Gay, Bisexual and Transgender Issues in Counseling’s (ALGBTIC’s) competencies for providing group counseling to LGBT clients. ASGW also has practical resources to augment your group counseling skills through its Group Work Experts Share Their Favorite Activities series. Combining these resources with information acquired from SAMHSA and the tips in this article should prove helpful in designing and running effective groups for clients in MAT in integrated care settings.

Conclusion

As integrated care becomes more widespread, counselors must adapt their practice of counseling to the environment and to the full range of client needs. It is a counselor’s duty to utilize the benefits that integrated care has to offer, such as immediate and continual collaboration with treatment team members.

For clients in MAT, group counseling in integrated care can provide a multitude of benefits, including the opportunity to learn from each treatment team member, the opportunity to build community in the journey to recovery and accountability. To enhance group counseling in these settings, counselors might consider:

  • Including education from each service provider in the early stages of the group
  • Seeking dual licensure or relevant continuing education opportunities
  • Implementing theories that are suitable for the client issue and the setting
  • Using resources made available by SAMHSA and professional counseling organization such as ACA, ASGW and ALGBTIC

Implementing these tips and resources will result in a fresh and efficient group counseling experience for clients in MAT in integrated care settings.

 

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Stephanie Maccombs is a second-year doctoral student in the counselor education and supervision program at Ohio University. She is a licensed professional counselor and chemical dependency counselor assistant in Ohio. She has worked as a home-based addiction counselor and currently works in a federally qualified health center providing mental health and chemical dependency counseling services to adults participating in medication-assisted treatment. Contact her at sm846811@ohio.edu.

 

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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.

Finding balance with bipolar disorder

By Laurie Meyers April 24, 2018

Licensed professional counselor (LPC) John Duggan didn’t plan on bipolar disorder becoming one of his specialties, but providing emergency room support gave him a close-up view of the consequences when the disease was left uncontrolled. Duggan, who is also a licensed clinical professional counselor (LCPC), noticed the escalation in manic and hypomanic crises that accompanied the increased light and time change in spring. He also saw people who had been diagnosed with depression but whose manic or hypomanic symptoms had gone undetected until they ended up in the emergency room with full-blown mania, psychosis or dysphoria.

Some of these individuals had no one to help them remain stabilized after leaving the hospital. Seeing the need for, as Duggan puts it, “boots on the ground,” he began seeing more and more clients with bipolar disorder in his private practice in Silver Spring, Maryland. Duggan, who is now the manager of professional development at the American Counseling Association, says some of those clients came as referrals from counselors who didn’t feel qualified to work with individuals struggling with bipolar disorder.

It is not uncommon for counselors to be hesitant to take on clients with a bipolar diagnosis, according to practitioners who specialize in the disorder. At the same time, there are many individuals with bipolar disorder who truly need the support of counselors and other mental health professionals to help them manage their condition. Although the public — and perhaps even some mental health professionals — may think that the disease is rare, the National Institute of Mental Health (NIMH) estimates that approximately 2.8 percent of U.S. adults currently have bipolar disorder and that 4.4 percent will experience it in their lifetime. NIMH also estimates that approximately 2.9 percent of adolescents currently have bipolar disorder.

Some mental health practitioners may buy in to the stereotype that clients with bipolar disorder are volatile and resistant to treatment, whereas others may be daunted by the disorder’s elevated risk of suicide. The Substance Abuse and Mental Health Services Administration estimates that for those with bipolar disorder, the lifetime risk of suicide is at least 15 times higher than it is for the average person. However, Duggan and others who treat bipolar disorder say that counselors have a crucial role to play in helping clients manage the disease.

Bipolar basics

Counselors are already trained to obtain a detailed client history that includes, among other things, emotional symptoms, family history and sleep and lifestyle habits, all of which can be crucial to spotting bipolar disorder.

“Bipolar clients often seek help only when depressed. Because of this, their manic or hypomanic symptoms are often not reported or observed,” explains Valerie Acosta, an LPC who counsels a number of clients with bipolar disorder in her Richmond, Virginia, practice.

A first step is for counselors to educate clients. Although they may be familiar with the symptoms of depression, they are much less likely to know how mania or hypomania present, adds Acosta, a member of ACA. Many clients think mania involves feeling very “up” and happy, but symptoms actually include intense irritability, anxiety and distraction, she explains.

Sleep patterns are also instructive when looking for evidence of mania or hypomania, says Regina Bordieri, a licensed marriage and family therapist in New York who specializes in bipolar disorder. “If they’re not sleeping, are they feeling energetic or tired?” she asks. Most people feel tired after a short night’s rest, but in hypomanic or manic phases, those with bipolar disorder feel energized despite very little sleep, Bordieri explains.Bordieri also asks clients about times when they weren’t depressed. Did they have high levels of energy and feel like they could get a lot done? Depressed moods that alternate with periods of intense activity and feelings of almost limitless energy may be signs of bipolar disorder.

Because it can be difficult for individuals to recognize their mood and behavioral shifts, family members and partners can also play a significant role when it comes to identifying and gauging symptoms, Bordieri says. Then, of course, there is the other role that family plays in diagnosis — namely, family history. Bipolar disorder is strongly tied to genetics, so clients with a family history of bipolar disorder are more likely to develop the disease.

Duggan urges counselors who are treating clients with bipolar disorder to work closely with medical professionals. Consulting a client’s primary care physician (with the client’s permission) is particularly crucial during diagnosis so that physical causes such as sleep disorders, thyroid disorders or a reaction to medication won’t be mistaken as symptoms for bipolar disorder.

Counselors — and clients — should also be aware of their ideas concerning which symptoms and forms of bipolar disorder are most debilitating, say Acosta and Bordieri.

“Bipolar II is not a milder form of bipolar I, but a separate and different diagnosis,” Acosta explains. “Bipolar I is also not necessarily more difficult to treat. … While the manic episodes in bipolar I can be severe and dangerous, the depressive episodes associated with bipolar II can be longer lasting, causing severe impairment to the individual. While clients with bipolar II have hypomania and not full manic episodes, their depressive episodes can be more debilitating than the depressive episodes of bipolar I.”

Although the depression of bipolar II may take a greater overall toll and be harder to treat, the mania inherent in bipolar I comes with its own set of “baggage.” In the popular imagination, mania — especially more extreme episodes — is the phase most associated with bipolar disorder and contributes to the perception that those who have the disorder are “crazy.” Mania is also extremely disturbing for clients and is highly stigmatized, especially when it leads to hospital stays, Bordieri says.

Ultimately, however, each client’s experience of bipolar disorder is different, Acosta says. “A therapist might be working with two people with bipolar II, and these individuals may present with very different symptoms,” she says. “Helping clients and their families to understand the individual’s unique symptoms, and have a variety of tools and strategies for managing their moods and specific symptoms, is essential for recovery.”

Managing medication

The counselors interviewed for this article stress that because of the neurobiological nature of bipolar disorder, medication is an integral part of treatment. Cheryl Fisher, an LCPC practicing in Annapolis, Maryland, whose specialties include bipolar disorder, says that counselors should work closely with a psychiatrist when treating these clients. In fact, when Fisher sees new clients with bipolar disorder who are working with a primary care physician, she strongly urges them to begin seeing a psychiatrist. Fisher, a member of ACA, believes that psychiatrists possess the specialized psychopharmaceutical knowledge necessary for prescribing the medication “cocktail” that works best for each individual with bipolar disorder. And because counselors see clients more often (and for longer chunks of time) than their physicians do, Fisher thinks that counselors are in a better position to track the effectiveness and side effects of clients’ prescriptions.

Counselors can also help clients become better self-advocates, says ACA member Dixie Meyer. Sometimes clients aren’t comfortable speaking up at the doctor’s office or are unaware that they are even experiencing side effects, she says. Counselors are in a position to spot such problems.

Meyer gives the example of a client who was showing signs of lithium toxicity. “I asked him when was the last time he had his blood levels checked [lithium requires regular blood testing to guard against toxicity]. He asked me what I was talking about. Somehow, he never knew he needed to have levels checked regularly.”

Meyer, an associate professor in the medical family therapy program at the St. Louis University School of Medicine’s Relationships and Brain Science Research Laboratory, says counselors should also be aware that clients with bipolar disorder might be given antidepressants for depression that can cause the onset of mania or hypomania.

“Clients might feel like, ‘Wow, I’m really starting to have a good mood,’” she notes. “They don’t really think to bring that up to the doctor, but the counselor can easily recognize the difference between remission of depression symptoms versus the development of manic symptoms. [Clients] might become more impulsive, snippier, their motor behavior more agitated … Counselors and family members are often the best [resources] to spot mood shifts.”

Sometimes clients don’t want to take medication for bipolar disorder because they have experienced unpleasant side effects, says Meyer, who frequently gives presentations to counselors on the importance of understanding their clients’ medications. She urges counselors to talk through this decision with clients. Meyer informs her clients with bipolar disorder that all medications have side effects, some of which may be temporary. She then asks these clients to give the medications some time and encourages them to talk to their physicians about which side effects might be permanent.

If the side effects of the medication aren’t going to go away, Meyer talks with clients about whether the side effects are something they can live with. In some cases — especially with medications that cause significant weight gain — the client’s answer is no. In those situations, Meyer says that she, the client and the physician go back to the drawing board and look for other medications or explore whether lifestyle changes might help reduce the side effects.

Meyer says all counselors should have a copy of the Physicians’ Desk Reference on hand so that they can quickly look up any medication. She also recommends Drugs.com as an excellent online resource.

Sometimes clients with bipolar disorder get stabilized and decide that they don’t need to take their medications anymore. When that happens, Acosta says that she “reflects back” what happened the last time the client stopped taking his or her medication. (Spoiler alert: It wasn’t good.)

Fisher tries to educate clients about bipolar disorder, emphasizing that a biochemical reaction underlies their mood shifts and that the medication helps buffer that process.

Medication, however, is not the only tool in the box to help individuals with bipolar disorder. Counselors can provide the emotional and lifestyle keys that help clients manage and, hopefully, decrease their mood and behavior shifts.

Prevention and stabilization

Multiple research studies continue to demonstrate the link between the circadian rhythm and bipolar disorder. Researchers are still teasing out the specifics, but what is clear is that maintaining a schedule — particularly a sleep schedule — that hews to the circadian rhythm plays a key role in controlling the disease.

Research has shown that insomnia is not just a symptom of depression but can also cause it. Likewise, Bordieri says, disturbed sleep can be either a symptom of hypomania/mania or the trigger for an episode.

Sleep is one of the first things that Fisher investigates with all clients, but it is particularly important in those with bipolar disorder. “I ask them what their sleep routine is,” she says. “How do you end your day? How do you prepare your body to rest? What is your sleeping environment like?” Fisher talks about how the blue light from devices such as smartphones and tablets disrupts sleep and advises clients to establish total darkness in their bedrooms.

Some clients reveal that a racing brain regularly prevents them from going to sleep. For these clients, Fisher recommends tools such as guided meditation or performing what she calls a “brain dump” — emptying the mind by writing down all of the thoughts that are keeping clients awake.

Acosta encourages clients with bipolar disorder to go to bed at the same time every night, wake up at the same time every day and take their medications at the same time daily. She has found this routine has a stabilizing effect.

Fisher and Duggan both believe sleep is so essential to mental and physical health that if good sleep hygiene isn’t working, they advise clients to get a sleep aid from their physician.

Duggan has found that the changing of the seasons can also have a profound effect on bipolar disorder. It’s a component of the bipolar resiliency program he came up with called SMART.

S — (Control) stress, sleep, maintain a schedule, seasons: Duggan asks clients with bipolar disorder to track their moods and sleep. He also teaches sleep hygiene and makes note of clients’ responses to the different seasons. Summer, when there is a lot of activity going on and plenty of sun, is usually a good time for many clients with bipolar disorder. But as the season draws to a close, Duggan reminds them that once fall arrives and there is less light, they are likely to start feeling less upbeat and may feel overwhelmed. He urges these clients not to overschedule themselves in summer and to step up their self-care efforts when the calendar turns to September.

M — Medication as prescribed

A — Adjunctive treatment such as yoga, acupuncture, massage or other complementary or alternative practices: Duggan says these are all areas that are outside of his expertise but that clients have found helpful. He also works with clients on self-soothing techniques and meditation. If a client is going through a severe manic or depressive phase, however, he strongly recommends against mindfulness. “I don’t want them to ‘be’ with the bad depression or the bad mania,” he explains.

R — Recreation and relationships: Duggan urges clients with bipolar disorder to stay engaged socially and to “do things that bring you joy, that you love, that give you a sense of flow.”

T — Therapy and counseling as needed

Fisher is a proponent of what she calls “nature therapy.” Research has shown that nature has a beneficial effect on mental health, so she urges clients to find a way to get outside — even if only for a short time — every day.

“Encouraging clients to track their moods can be a very valuable tool,” Acosta adds. “There are a wide variety of apps that clients can download to help with tracking their moods. Daylio is one that a lot of my clients like to use. By recording this information over time, clients learn about how their moods cycle, and this helps them to better understand the nuances of their moods, their triggers, and what helps and does not help with stabilizing their moods. I routinely review data from these apps — or paper mood charts — with my clients. I also routinely review symptom charts with my clients to help them monitor their symptoms.”

Some of Acosta’s clients have also had their own highly personal methods of tracking problematic mood changes. One client monitored her mood elevations by the number of packages that appeared for her in her apartment lobby (overspending). Another client could connect his manic symptoms to times when he would spend several days engrossed in building things (an increased focus on goal-directed activities).

Developing this degree of self-awareness can be beneficial for clients with bipolar disorder. “Linking symptoms to behaviors, thoughts and triggers can help to foster recovery,” Acosta says.

Meyer also teaches clients to spot patterns. She has premenopausal women chart their menstrual cycles so they will be aware, for example, that three days before their periods begin, they will feel more depressed. Meyer instructs clients to note their moods throughout the day and record what was going on. She believes that when clients can identify these patterns and recognize that there was a specific reason they were particularly manic or depressed, it provides them a greater sense of control.

Meyer teaches clients to self-soothe on hard days by going for a walk, going to the park and sitting on a bench or doing whatever else makes them feel good in a healthy way. 

“It’s really important … that our clients be empowered with a strategy for their symptoms,” Fisher says. For instance, if clients with bipolar disorder are having a down day and feel as though they are shifting toward a depressive episode, they could start to manage the switch by making a plan to get together with a friend or even just calling someone close to them.

Acosta tries to equip clients with bipolar disorder against life stressors. “They need to find healthy ways to cope with stress,” she says.

Acosta teaches clients mindfulness meditation and gives assignments outside of session, such as trying yoga or a new form of exercise. She believes that physical activity helps rein in racing thoughts. Acosta also recommends music for relaxation.

Seeking support

In addition to individual therapy, Acosta has found that group therapy is very effective for clients with bipolar disorder. She runs a monthly support group for adults over 18. “Some participants have been living with bipolar disorder for decades, and some have just been diagnosed,” Acosta says. “This is an open group, so members are constantly joining and leaving the group. On average, we have three to 10 participants per group. Because this is a therapy group, participants bring in and discuss any issue that they’re currently dealing with in their lives. Some of the topics of discussion include challenges such as the struggle to be on time for work or losing a job because of their bipolar symptoms, relationship conflicts, the side effects of medication, healthy strategies for managing symptoms, grieving the losses in their lives caused by their illness and building healthy living strategies.”

Acosta also provides education as needed in the group on topics such as understanding symptoms, exploring apps to track mood and locating resources for further education and support. She believes the peer support is what is most helpful to group participants.

“Many people have never met someone else with bipolar disorder, and learning that they are not alone or the only person dealing with the challenges of bipolar disorder can be extremely comforting and helpful,” she says. “Seeing peers recover, build healthy relationships and obtain their goals and dreams is most powerful.”

Support for these clients is essential, agrees Meyer, who recommends that counselors help recruit family members and romantic partners as a kind of support team whenever possible. Loved ones can be there when counselors can’t and are often the first to spot mood changes, she explains. “We also know when clients are in good, healthy relationships, it helps stress levels, and that helps keep them in good health,” Meyer adds.

Sometimes support can come from the strangest of sources, notes Fisher, relating the story of a woman who was in particular need of connection. “I had a client who had a trauma history in addition to bipolar disorder, and she was engaging in really unhealthy behaviors and self-loathing. She was just not in good shape,” Fisher says. “She came in one day, I did a checkup, and she showed really high levels of depression.”

Fisher didn’t think the client was in immediate danger, but she felt bad leaving her without another source of support, particularly because it was a Friday and Fisher was going away for the weekend.

“I asked, ‘Who can you be with? Who can you talk to?’’ Fisher says. “The client said, ‘No one. There is no one.’”

The woman was estranged from her family, and her only “network” involved her sexual hookups.

Suddenly, Fisher had an idea. She had just bought a betta fish for her office, so she asked the client to watch it for her over the weekend.   

Fisher saw the client the following Monday — sans fish — and asked how she was doing. The client replied that she was feeling better and more upbeat.

“Then she started talking about her weekend and spending time with ‘Olive’ and watching TV with ‘Olive,’” Fisher continues.

She asked the client who Olive was. Olive was the name the client had bestowed on the betta fish. The client had neglected to bring Olive back because she didn’t want to leave the fish in the car but promised to return her later in the week.

Fisher told the woman to keep the fish but was curious as to why she had named her Olive. The client said that Olive made her think of hope — like the olive leaf the dove brought back to Noah’s Ark to show the waters were finally receding after the Great Flood described in the Bible.

What lesson did Fisher take away from this experience? “We have to get our clients to connect — even if it’s just with a betta fish,” she says.

Fisher urges counselors to overcome any reservations they might harbor about treating clients with bipolar disorder. “Get more training if you’re uncomfortable,” says Fisher, who encourages counselors to ask themselves why they might be uncomfortable and then to address those reasons.

Counselors already possess the skills needed to empower these clients, Fisher adds. “We have clients who are walking in the door with this diagnosis and identifying it with who they are,” she says. “Bipolar disorder is not who they are — their diagnosis is not their identity. People think, ‘My body is betraying me. I feel like crap. I’ve alienated all my friends — I am the monster.’ Counselors can exorcise the demon of the [bipolar] diagnosis.”

 

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Additional resources

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

Counseling Today (ct.counseling.org)

Books (counseling.org/publications/bookstore)

Podcasts (counseling.org/knowledge-center/podcasts)

  • “Bipolar Resiliency Program” with John Duggan (HT056)

Webinars (aca.digitellinc.com/aca)

  • “Depression/Bipolar” with Carman S. Gill

Practice briefs (counseling.org/knowledge-center/practice-briefs)

  • “Counseling Adults Who Have Bipolar Disorders” by Victoria Kress, Stephanie Sedall and Matthew Paylo

 

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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.

 

Fried chicken, watermelon, addiction and Appalachia

By Gerard Grigsby February 8, 2018

Hearing jokes about watermelon and grape Kool-Aid. Hearing someone talk about their “half-colored” nephew’s “nappy” hair. Being called “boy.” This is what I experienced over the year that I led an addictions process group in rural Appalachia.

After working in the area for almost four years, I had grown accustomed to hearing these types of comments, but the straw that broke the camel’s back was a response made in group after one member shared that she was dating outside of her race for the first time.

This particular group member said that she was no longer interested in “full-blooded white men.”

“Yeah, you like him now, but wait until he blacks your eye,” another group member commented.

We were gathered outside on a warm, sunny spring day, but a storm cloud of mixed emotions swept over me as I sat there in disbelief. As the leader of the group and the only person of color among a group of eight, I was at a total loss for words. I had no idea how to address what had been said, and I was too overwhelmed to convey exactly what I thought or felt in that moment.

I knew I felt invisible. I knew I felt voiceless. But without any guidance, I struggled to determine what my response should be or whether it would even be appropriate to share what I was feeling. Ultimately, I chose to remain silent and let the moment pass as if nothing had happened, but the weight of what had transpired lingered with me long after our group meeting had ended.

By the time I arrived home that evening, my initial shock and disbelief had transformed into anger and disappointment. I had been really fond of the group member who made the offensive comment, so it stung to hear him perpetuate such a harmful stereotype about people of color. It didn’t help that he had made this comment after I had worked so hard to be understanding and sensitive to the needs of the group, especially considering that many members perceived that their backgrounds made them targets for judgment and mistreatment by law enforcement, family, friends and even other counselors.

I had also worked very hard not to perpetuate stereotypes about people who are in recovery from addiction, and I had avoided repeating the derogatory language that is often used to describe the people of Appalachia. What made matters worse is that just months prior, there was general consensus among the group that no one liked being called a “junkie” or an “addict,” especially by someone who has never used drugs. Clearly, these members knew what it was like to feel marginalized, so how could they allow someone in the group to make such a racially insensitive comment and not challenge him?

I went to bed that night still upset about what had happened and woke up the next day feeling even angrier. In fact, I thought about that incident for several days. I consulted with my supervisor and processed what it was like for me to have led the group that day. I shared the details of the incident with my colleagues in a separate supervision group. I spent hours brainstorming different ways to confront the group about what had happened. I thought to myself, “Maybe I should compile a list of derogatory terms, share them with the group and ask members what they think about culturally insensitive language. Maybe I should stop being so careful with my words and ask members how they feel when they’re on the receiving end of microaggressions!”

These ideas came from a wounded place in me. I had worked hard to protect my group members, and it hurt having to accept that they had not been as protective of me. Thankfully, ongoing self-examination helped me set aside my own baggage and reminded me that it would be harmful and unethical to prioritize my own needs over those of the group.

Instead, I did some more processing and eventually decided it was less important for me to get retribution and more important for me to leave the members with greater insight than they had before joining the group. I wanted to do something that would be meaningful and impactful for everyone in the group, including myself.

The next week, I sat everyone down and implemented a new group rule: Please be mindful of the diversity represented within the group. Without my having to confront him directly, the group member who had made the offensive comment the week before knew immediately why I had made this request and, to his credit, apologized for what he had said. Although I did not take the opportunity to share with the group exactly how his words had impacted me, the act of advocating for myself and others in the group was healing enough.

In fact, addressing diversity issues that day served as a critical moment for the group and opened the door for continued discussions about race, culture, sexual orientation and other aspects of multiculturalism. Just a few weeks later, for example, a group member made a comment about fried chicken, to which I lightheartedly responded, “Is this another racist joke?” To my relief, the group laughed, and we went on to have a productive conversation about ethnicity, regional diversity and similarities between Appalachian culture and African American culture.

In hindsight, I don’t know if I used the best approach to address diversity issues in my group, but I can look back and appreciate how that first challenging experience (there were others afterward) helped to shape my counseling philosophy and improve my group counseling skills. It taught me when and how to address diversity issues in groups, and it served as a reminder that multicultural issues are always relevant, even in an addictions process group in rural Appalachia.

 

My recommended resources

If you have been in a situation similar to mine, or would simply like more guidance on addressing diversity issues in addiction counseling groups, check out the following books:

  • Group Exercises for Addiction Counseling by Geri Miller (2012)

Miller describes two activities that can be used to address diversity issues in addiction counseling groups. My favorite of the two, “Sharing Culture,” is a dynamic group activity that facilitates engagement, information sharing and processing. I won’t provide any spoilers if you haven’t read the book, but just know that this activity involves yarn and sounds like a lot of fun.

  • Group Work Experts Share Their Favorite Activities for the Prevention and Treatment of Substance Use Disorders, published by the Association for Specialists in Group Work (2015), and edited by Christine Bhat, Yegan Pillay and Priscilla Selvaraj

This book is full of engaging activities for anyone interested in group work, but one activity in particular may be useful for practitioners who want to address diversity issues in group. Submitted by Beverly Goodwin and Lorraine Guth, this activity requires group participants to identify what they know about their own ethnic, racial or cultural group, and then consider how different aspects of their identity impact their recovery.

My own spin on this activity would involve an initial discussion about drug culture — its norms, unspoken rules, daily practices and common beliefs of which people may be unaware. I see this as a helpful way to set the stage for a broader discussion about culture and diversity. I also think it would be a useful way to help group members process the fact that they are indeed giving up certain aspects of a valued cultural system when they decide to start their recovery. This context can help enrich subsequent discussions about culture, assimilation and acculturation as members discuss the process of letting go of drug culture and embracing aspects of other cultural systems that may be less harmful.

 

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A version of this article was originally published in the December e-letter of the Association for Specialists in Group Work, a division of the American Counseling Association, and is used here with permission.

 

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Gerard Grigsby is a fourth-year doctoral student in the counselor education and supervision program at Ohio University. He is licensed as a professional counselor in Ohio and has worked in college counseling and community mental health settings. Currently, he works at a substance use treatment clinic, where he has the privilege of serving and learning from individuals in recovery. Contact him at ggrigsby@hrs.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.

Group counseling: Neglected modality in private practice

By Kevin Doyle March 7, 2017

After approximately 25 years of working in private agencies, I started a part-time private practice a few years ago focusing on my specialty area of working with clients with substance use disorders. Having worked largely with adolescents, I was looking forward to working more frequently with adults, especially after I had the realization that I was growing older and the adolescents were not.

One of my first efforts at outreach was to my state’s monitoring program for licensed health care providers (doctors, nurses, dentists, veterinarians and so on) because I was aware that these professionals are at high risk of substance use problems for a variety of reasons. Over the past eight-plus years, I have found this area of practice to be both stimulating and professionally rewarding.

As is the case in most states, my state mandates that health care professionals must, following an issue related to a substance use or mental health disorder, participate in its monitoring program for five years to ensure professional oversight during the transition back to practice. I quickly realized that the need for individual counseling throughout the full five years, although potentially appropriate in some cases, was likely not indicated in many instances. So, I approached several nurses in the monitoring program about starting a counseling group. They were open to the idea and even enthusiastic. Eventually, I asked them about including a physician. Their response to my question was memorable: “Don’t worry. We can handle him.”

Since that time, the group has grown to include several other health professions and has ranged in size from six to eight individuals. According to the participants’ report, it is helpful to be exposed to the input and perspective of others who have been through the process of addiction (sometimes diverting medications from patients and facing criminal prosecution) as they work to put their lives back together and obtain approval to return to professional practice.

Using this experience, I have subsequently established two more recovery support groups in my practice. Both groups are for men in early recovery from substance use disorders, which constitutes a large portion of my clientele these days. In talking with other counselors in private practice, however, I have learned that very few offer group counseling, preferring to stick to the traditional model of one-on-one counseling. Why don’t more counselors offer group counseling?

Potential advantages

The ACA Code of Ethics includes standards relating to group counseling, including A.9. (Group Work) and B.4. (Groups and Families). Although these standards identify responsibilities that counselors have when choosing to provide group counseling services, none of them includes any admonition for counselors to consider offering group work.

What, then, are the potential advantages? Let’s look at three that are most commonly identified.

1) Cost to the client/payer: A ballpark calculation, based on discussions I have had with other counselors, as well as rates posted on websites, is that the per person rate for group counseling is about one-third to one-fourth of the rate that counselors tend to charge for individual sessions. Using an example on the higher end, a counselor who charges $150 for a traditional therapeutic hour (a 45- to 50-minute session) would probably charge $40-$50 per person for group counseling. Many counselors also extend group sessions to 70-90 minutes to allow adequate time for each member to participate. In this day of tightly managed insurance benefits, the cost to the payer is much less in group counseling and tends to give clients the ability to participate for longer periods of time, which is often extremely beneficial.

2) Additional revenue for the practice: Not to be overlooked is the potential that group counseling offers for a practice to enhance revenues. There are only so many hours in the week and a limit to how many clients an individual practitioner can be effective in seeing. High-end estimates tend to run to seeing clients 25 to (at most) 30 hours per week, thus still leaving time for documentation, marketing, practice management, breaks, supervision, etc. Given overhead expenses such as liability insurance, rent, phone service, office supplies and equipment, internet/web access, licensing fees and more, it is challenging for counselors to make an adequate living without following sound business practices. One of these practices can be to offer group services.

3) Enhanced therapeutic value: Finally, as the ACA Code of Ethics stresses, we should ultimately make decisions with our clients in mind, keeping whatever is best for them paramount in our thinking. Both research and anecdotal evidence support the provision of group services as an important part of addressing many clients’ needs, with substance use disorder being a clear example. The experience of hearing from other people who are both struggling with the same issues and having success addressing those issues can be life-changing for clients. Likewise, establishing a support network that people can draw on outside of sessions can also be very therapeutic and is an important outgrowth of group work.

Potential disadvantages 

What, then, might be the disadvantages, and why do so few counselors in private practice offer group services?

1) Scheduling: One of the great benefits of owning a private practice for many counselors is the flexibility it affords them in both their personal and professional lives. In my experience, the days of the client who comes in every Wednesday at 10 a.m. are no longer; in most cases, they have been replaced with a more flexible, variable style. This also gives the counselor the ability to work around a full- or part-time job, family obligations, vacations and other scheduling issues.

Groups, however, typically do meet at the same time every week, every other week or monthly. Rescheduling a group involves potentially inconveniencing eight to 10 participants, as well as the counselor, and is much more complex and problematic than rescheduling an individual client. Although I will occasionally reschedule a group in my practice, I usually hire another local practitioner to cover the group, obtaining a release of information from group members to facilitate client coordination with the other practitioner. Having a substitute counselor can supply a healthy change of pace for groups and can enhance the group process in future sessions too.

2) Lack of comfort with group modality: Group counseling classes are included in most counselor training programs, but it is possible for counselors to move quickly into a comfort zone of providing services on a one-to-one, individual basis and allow their group counseling skills to grow rusty. For many counselors, the transition to private practice begins as a part-time arrangement in combination with another full-time job. Thus, it may be many years before the counselor is fully engaged in private practice work as his or her primary activity. This may further contribute to the lengthy delay between when a counselor receives group skills training and finally implements those skills in a private practice setting. This is not the only scenario under which counselors move into working privately for themselves, but this pattern may partially explain why so few private practitioners offer groups.

3) Too much effort to establish: Finally, and related to the scheduling challenges noted earlier, there is the effort required to get a group off the ground. Persuading clients that group counseling is an option worth considering can sometimes be a formidable obstacle.

I recall one particular client of mine who was dead set against group work, indicating that he did not want to share his “personal business” with a group of strangers. After nearly two years of relatively successful individual counseling related to his problems with alcohol, he experienced a serious relapse, leading to inpatient treatment — where groups were a large part of the service delivery system. Upon returning to the community, he has engaged with his group and finds it to be an essential part of his overall recovery program.

On a more mundane level, simply finding a time that works for all potential members and the counselor can be a significant challenge. I have had some luck holding groups early in the morning, before many people start their workdays. Other options might include lunch-hour meetings, evening sessions or even weekend slots. Sometimes, however, the difficulty of establishing a regular meeting time can be so daunting that it prevents counselors in private practice from even attempting to start groups.

Conclusion

In summary, groups can provide a tremendous therapeutic opportunity for our clients to address their issues with the assistance of others who are confronting similar problems. Counselors should consider this modality more frequently as they look to simultaneously improve their work with clients and solidify their private practices from both a quality and financial standpoint.

Opportunities for retraining for those professionals who have not had group experience since graduate school are abundant. These opportunities include myriad continuing education options such as conferences, webinars and self-paced reading. Additionally, counselors can partner with other professionals in a co-facilitation arrangement. This may negate some of the financial upside of group work, but it can also assist in providing built-in coverage should a counselor need to miss a session.

Ultimately, as we ponder as counselors how best to meet the needs of our clients, group work should be something that we all consider as part of our ethical responsibility.

 

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Kevin Doyle, a licensed professional counselor and licensed substance abuse treatment practitioner, is chair of the Department of Education and Special Education and an assistant professor of counselor education at Longwood University in Virginia. Contact him at doyleks@longwood.edu.

Letters to the editor: ct@counseling.org

Counseling Today reviews unsolicited articles written by American Counseling Association members. To access writing guidelines and tips for having your 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.