Tag Archives: Group Work

Group Work

More than simply shy

By Bethany Bray July 29, 2019

Social anxiety is different from — and much more than — simply being shy or introverted or having poor social skills. Even so, people who live with social anxiety often find the disorder trivialized or minimized by others, including some mental health professionals, according to Robin Miller, a licensed professional counselor (LPC) and a member of the American Counseling Association.

“Shyness doesn’t necessarily have a negative impact on someone’s life. That’s an important thing to remember from a clinical point of view,” explains Miller, who specializes in working with adults with anxiety disorders at an outpatient practice just outside of Milwaukee. “Many of my clients get a pat on the head from people and [comments such as], ‘You’re just shy. You have nothing to worry about.’ But you wouldn’t get that for [symptoms of] posttraumatic stress disorder or other mental health issues. You wouldn’t say there’s nothing to worry about.”

Most of all, clients with social anxiety need support and reassurance as they try to discontinue old patterns and behaviors that they have adopted to cope with the paralyzing fear that often accompanies the disorder, says Brad Imhoff, an LPC who was diagnosed with social anxiety disorder in 2012 as he was working on his doctorate.

One characteristic of social anxiety is a constant feeling of apprehension regarding social situations. It is difficult to express just how oppressive and pervasive that feeling can be, says Imhoff, an assistant professor of counseling at Liberty University who lives in central Ohio and teaches in the university’s online program. “You carry this feeling of ‘I just can’t do this’ all the time,” he says. “As human beings, we’re social. And apprehension in every one of [those social situations] can be overwhelming.”

Imhoff, a member of ACA, says he recognizes the irony of his career choice: a person with social anxiety who speaks regularly to rooms full of people, both as a counselor educator and as a frequent presenter at conferences, including giving a session on social anxiety at the ACA 2019 Conference & Expo in New Orleans.

Imhoff has learned to navigate the challenges of social anxiety since his diagnosis, but he acknowledges still feeling anxious before speaking engagements. “The question is, how do I manage it and not let it get in the way of life?” he says. “I will have to manage this, to some extent, for my entire life and not let it get to the extremes it has in the past.”

Navigating life through avoidance

Social anxiety is one of a number of related issues — including specific phobia, panic disorder, separation anxiety disorder, generalized anxiety disorder and others — that fall under the anxiety heading in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders.

Called social phobia in decades past, social anxiety disorder is characterized by persistent fear over social or performance-related situations, according to the National Institute of Mental Health, which cites diagnostic interview data to estimate that 12.1% of U.S. adults will experience social anxiety disorder during their lifetime. Among adolescents ages 13-18, the lifetime prevalence is 9.1%. For all ages, social anxiety disorder is more prevalent in females than in males.

Researchers have not singled out a specific cause for social anxiety disorder, pointing instead to a combination of biological and environmental factors as contributors. Genetics appears to play a large role in many cases, as can negative childhood experiences such as family conflict or being bullied, teased or rejected by peers. It is also believed that individuals who have an overactive amygdala may experience more anxiety in social situations.

According to the Center for the Treatment and Study of Anxiety at the University of Pennsylvania, “Social anxiety disorder can affect people of any age. However, the disorder typically emerges during adolescence in teens with a history of social inhibition or shyness. The onset is usually accompanied by a stressful or humiliating experience, and the severity varies by individual. … There is a higher incidence of social anxiety disorder in individuals with first-degree relatives affected by other panic and anxiety disorders. However, there is no one gene that explains this biological trend. General findings indicate that personal experiences, social environment and biology all play a role in the development of the disorder.”

People often experience symptoms of social anxiety disorder to varying degrees across the life span, according to the center. Symptoms may lessen for stretches of time and then worsen during periods of change or stress, such as a job transition or when dealing with feelings of grief and loss.

What sets social anxiety apart from general anxiety is not only the social component but also an intense fear of judgment by others, explains Holly Scott, an LPC whose Dallas private practice is a regional clinic of the National Social Anxiety Center. People with social anxiety often harbor strong and pervasive feelings that others will notice their anxiety and judge them, which triggers avoidance behaviors, she says.

At the same time, there are nuances to the diagnosis, and social anxiety can look different in each client, Scott adds. For example, someone may be fine with public speaking and yet not be able to walk into a room in which they don’t know anyone.

“People think it’s not treatable,” Scott says. “Clients label it as ‘this is just the way I am, and I can’t change the way I am.’ It can be difficult to treat or to find a qualified practitioner, but it is treatable.”

Imhoff says he has read that on average, people go 15 years before seeking treatment for social anxiety. Counseling itself is a social interaction, he notes, and people with social anxiety may avoid treatment out of a fear of the close interaction or of being scrutinized by a practitioner.

Because people with social anxiety typically adopt avoidance as one of their coping mechanisms, and perhaps because of the way that social anxiety tends to get minimized or passed off as simply being introverted or shy, these clients often live life without seeking treatment until they reach a breaking point. As Imhoff points out, people can self-manage their social anxiety for an extended period of time by maintaining the same small circle of friends and following certain behavioral patterns such as always using the self-service checkout line at the grocery store.

Living with social anxiety is their reality, Imhoff explains, and they “forge ahead until something causes [them] to realize it’s more significant.” For Imhoff, that “something” was the impending scrutiny involved in defending his doctoral thesis.

“For social anxiety, it’s possible to navigate life with avoidance and survive for a long time. Then something comes up — a life change, such as entering the workforce — that causes them to need help,” he says. “A lot of these safety behaviors aren’t being done consciously. They are things we’ve done throughout our lives to find safety.”

Assessment and core beliefs

Avoidance behaviors are one of the biggest red flags that a client might be dealing with social anxiety, Miller says. These behaviors can extend to staying in situations in which the person is unhappy yet comfortable, such as a bad romantic relationship, a toxic friendship or a job that the person doesn’t enjoy or isn’t advancing in.

Other indicators include rumination and overthinking social experiences. This can include asking oneself over and over again, “What did that person think of me?” Miller explains, whether it’s an interaction with a neighbor while walking the dog or a yearly performance evaluation with one’s supervisor.

Counselors should be aware that social anxiety often co-occurs with other mental health issues such as depression and substance abuse (which often becomes a coping mechanism) that may need to be treated first or in tandem with the disorder, Miller adds. In addition, other issues such as grief may be complicating a client’s social anxiety. “They’re not always struggling with one thing. Make sure you’re working on what they’re struggling with the most,” Miller says.

Scott suggests asking clients at intake about how they deal with social situations and how often they go to gatherings or parties. Are they uncomfortable introducing themselves to new people, making a phone call or using the restroom in public places? If Scott hears symptoms that might indicate the presence of social anxiety, she uses a questionnaire (she recommends the Liebowitz Social Anxiety Scale, available at nationalsocialanxietycenter.com) to pinpoint the client’s fear level and to identify goals to focus on in therapy.

It can also be helpful to identify a client’s core beliefs and values and how those are affecting the person’s choices and behaviors, Imhoff says. People with social anxiety often carry a core belief that they’re inadequate or inferior, which spurs a fear of being judged, he explains. These clients frequently place weight and focus on situations that seemingly confirm their core belief and discount those that might disprove it. They might ruminate over a conversation with a colleague that didn’t go well, for example, without giving any consideration to all of the past conversations that did go well, Imhoff notes.

“They move through life paying very close attention to and taking to heart scenarios that confirm their core belief,” he says. “It’s important to help the client take off the blinders. Talk through ways they are competent, and get to the root of their concerns. Be aware of the multitude of their experiences and not just those they struggle with.”

To identify core beliefs, counselors can listen for themes in the way that clients talk about themselves, other people and the world. These themes can suggest deeply held beliefs to challenge or to explore further in therapy. Having clients work on thought journals can also be helpful in finding patterns, Imhoff says. He also suggests using a prediction log, in which clients name upcoming social scenarios that make them anxious and describe what they assume will happen. After the scenario occurs, clients can look back at their predictions with the counselor to talk through how accurate these foresights were.

After core beliefs and values have been identified, the counselor can work with clients to reframe their perspective around new core beliefs. For example, clients who place value on providing for their family could focus on that value to help them overcome their anxiety and discomfort over applying for a new job.

“Look for evidence that supports their new core belief,” Imhoff says. “If their belief is ‘I am capable,’ have them write down even the most minor piece of evidence [in a journal]. It makes it concrete and documented so they can refer back to it and talk it through with a counselor.”

From there, the counselor can work with clients on challenging cognitive distortions and black-and-white thinking, Imhoff suggests. Acceptance and commitment therapy (ACT) can be helpful, as can guiding clients to adopt a growth-focused orientation. With that mindset, every social interaction becomes an opportunity to learn rather than a pass-fail situation, Imhoff explains.

Clients with social anxiety may also feel that they’re failing because they can’t assume an extroverted, life-of-the-party façade. Counselors can help these clients learn that there is a continuum of social skills, Imhoff says. For example, perhaps they got through a work meeting and contributed their thoughts despite having a shaky voice and sweaty palms. “Work on [helping them realize] that it’s not black and white, it’s not all success or failure. There’s an in between for almost all scenarios,” he says. “Help them to recognize that in all social interaction, there is ebb and flow. It’s not a pass-fail exercise but an opportunity to connect with someone and learn moving forward.”

Additionally, ACT techniques can help clients learn to accept their anxiety rather than trying to get rid of it or avoiding triggering situations. Imhoff uses the imagery of “keeping anxiety in the passenger seat because I know it’s coming along but not letting it take control of the wheel.” Clients can learn to say, “There you are anxiety; I knew you were coming,” even as they move on with life and navigate situations they previously would have avoided.

Scott regularly uses cognitive restructuring and cognitive behavior therapy (CBT) with her clients who have social anxiety. She also uses a mindfulness technique called curiosity training that helps clients label their anxious thoughts as “background noise.” With this technique, users try to adopt an approach of curiosity about and interest in what is being said by others rather than assuming that others are judging them.

“In any situation,” Scott says, “whether they’re having a conversation, public speaking or sitting somewhere having lunch, they’ve usually got a constant dialogue going in their head. [It’s] self-criticism about how people must be thinking of them: ‘They don’t like my clothes’ or ‘I just stuttered while speaking.’ Curiosity training helps keep your mind on the present and learn how to pull your mind back when it starts wandering.”

Elizabeth Shuler, an LPC who has been working as an international school counselor in Amman, Jordan, for four years, recommends mindfulness techniques. She has often used Kristin Neff’s self-compassion practices in addition to dialectical behavior therapy, meditation and yoga for clients with social anxiety, both when she was in private practice in Colorado and Wyoming and currently in her work with adolescents and adults at her school.

“When we dig into their fears, most clients with social anxiety are really afraid that other people will agree with their own negative judgments of themselves. They’re worried that they will be proved right,” says Shuler, an ACA member. “I had a client who walked through the office the same way every day to avoid the people he was afraid of interacting with and had panic attacks when his route had to change or people he was avoiding crossed his path. These types of behaviors are meant to stave off panic but end up reinforcing it. My role as a counselor is to help clients see how these behaviors are actually making their panic worse and help them to slowly replace them with more helpful behaviors.”

Exposure

Exposure techniques are often central to treating social anxiety because they gradually reintroduce clients to anxiety-provoking situations in a healthy way.

Miller is trained in exposure and response prevention and finds it a powerful tool for working with clients with social anxiety. The behavioral technique requires clients to put in a lot of work themselves outside of sessions. The counselor collaborates with the client to develop a hierarchy of exposure based on the client’s needs and treatment goals and supports the client throughout the process.

As Miller explains, exposure assignments start small and build over time as clients become comfortable with each homework task. She describes this as a “Goldilocks situation” — not too much challenge and not too little, but just the right amount, tailored to each individual client. Miller says she emphasizes to clients that the treatment is in their hands — they have to do their part to experience a successful outcome.

“A lot of people have anticipatory anxiety, but once they do it [complete the exposure assignment], they’re OK,” Miller says. “A lot of people get over that hill of worry. They do it for a week or two and realize they can do it. Trust between a client and clinician is huge because we’re asking them to do really scary things.”

Miller often gives clients who are early in treatment the assignment of calling multiple businesses to ask what their hours are. Clients might have to overcome feeling a little foolish because that information is readily available on the internet, she notes. However, the goal is for clients to complete the task without falling back on habits they formed to avoid social situations, such as relying on technology in lieu of having personal interactions. Clients repeat the task over and over until they no longer feel anxious about picking up the phone and making a call, she explains.

Once they’ve mastered that task, clients might move on to going inside a store and asking a question in person. Or they might switch to walking their dog in their neighborhood during a busy time of day and saying hello to at least one other person during each walk.

As clients complete each task and return to their next counseling session, they process these interactions with Miller, discussing how the interactions felt to them and what went right or wrong. “Sometimes the client will come in and say, ‘I’m so bored with this.’ I say, ‘Great! That means it’s time to move on to something bigger,’” Miller says. “You need repetition with assignments. You need to do [tasks] over and over for your brain to get used to it. … The more you do it, [the more] it overwrites [old] patterns and anxious feelings.”

As a practitioner who specializes in treating social anxiety, Scott has a laundry list of exposure assignments that she uses with clients, ranging from making eye contact during a shopping trip to asking for directions from a stranger to calling into a radio talk show to singing karaoke. As clients progress, it can be helpful to assign them tasks that are certain to create some level of discomfort or awkwardness, such as going into Starbucks and ordering a hamburger, she says. This can be especially hard for clients who have a strong fear of being judged by others, but dealing with the responses they receive desensitizes these clients over time as they repeat the tasks.

Miller acknowledges that counselors may need to provide their clients with some ongoing motivation during exposure work. If clients come to session without completing their assigned tasks, she suggests asking leading questions to find out if they are avoiding the work or genuinely struggling to make it a priority among their other challenges.

“Who wants to go home and do anxiety-provoking things?” Miller says. “[We] have to find a way to motivate them. We want them to feel empowered to go out and do [an assignment]. Remind them that they’re in pain because something is not changing. … You can’t snap your fingers and make this go away. It’s going to be hard work and take time.”

It can be useful to circle back and remind clients of their core beliefs and the goals they want to achieve. For example, consider clients who say they ultimately want to start a family but whose social anxiety prevents them from entering the dating scene and potentially meeting a partner.

“They may not see how calling a drugstore [as an exposure assignment] is getting them to be able to date. But remind them that they’re building a foundation to be able to do that,” Miller says. “It may not have an immediate payoff, but the easier these things become for you, everything builds.”

Miller often uses the metaphor of training for a marathon to keep clients motivated. You don’t run 26.2 miles right away, she tells them. You start with one or two miles and then keep adding more distance, mile by mile.

Social skills

In addition to exposure work and cognitive restructuring, the counselors interviewed for this article recommend social skills training for clients with social anxiety. Avoidance behaviors may have kept these clients from learning and practicing social skills that are commonplace among their peers who do not deal with social anxiety.

“If you’ve been avoidant for years, you miss out on learning from all of the social interaction that others have had,” Miller says. “Sometimes they’ve built a life to minimize their pain, their anxiety.”

Goal setting and planning ahead, with support from a counselor, can help these clients navigate situations that are foreign to them and that naturally provoke anxiety. Miller suggests troubleshooting with clients. For instance, if their office holiday party is coming up, a counselor can talk through expected behaviors with clients and work on small talk and other exercises to help them get through the evening.

Setting realistic goals can also be comforting, Miller adds. “[They] don’t have to go in and work the room, [but] if they haven’t had a lot of social experience, they may not realize what’s expected,” Miller says. Instead, clients might set a goal of talking to three people whom they already know. Maybe at next year’s party, they can increase that goal from three people to five people.

Miller also reminds clients that a certain measure of social anxiety is simply part of being human. Even she, a therapist who makes a living talking to people, acknowledges sometimes being uncomfortable in social situations.

Kevin Hull is a licensed mental health counselor with a private practice in Lakeland, Florida, who specializes in counseling children, adolescents and young adults on the autism spectrum. Social skills training, along with group therapy, plays a large role in the work Hull does with clients around social anxiety, which he says often goes hand in hand with autism.

In individual counseling sessions, Hull uses puppets with clients to role-play social situations and work through what is expected. For example, Hull might instruct clients to verbalize a food order to his puppet without the usual help from mom or dad or ask his puppet for help finding a certain building on a school campus. Afterward, they process the experience together and talk about the emotions clients felt as their puppet had to interact and ask questions.

Humor can also be a great tool for overcoming the fear associated with social anxiety, says Hull, a member of ACA. He often shows clips of TV shows or movies (via YouTube) in client sessions as a lighthearted way of starting conversations about what is and isn’t appropriate when it comes to social skills. Particularly popular with clients are scenes with The Big Bang Theory’s Sheldon Cooper wrapping himself in bubble wrap to stay safe or wearing a second set of “bus pants” over his work outfit when taking public transportation. Another favorite is the title character in How the Grinch Stole Christmas, who initially can’t stand being around the Whos but ends up transforming over the course of the story.

“Using humor is a great thing to counter the fear,” Hull says. “When you can laugh at something, that gets people opening up and listening.”

Group work

Group therapy — a format in which clients are expected to interact with others and contribute to a discussion — would seem to be a nightmare for individuals who are socially anxious. But that’s not necessarily the case, according to Hull.

Although it can take clients some time to warm up to the idea, group therapy can play a powerful role in imparting the skills needed to navigate social anxiety, says Hull, an assistant professor and faculty adviser in Liberty University’s online master’s counseling program. In addition to helping participants sharpen their social skills, group counseling can instill perspective — something with which Hull’s clients who are autistic sometimes need extra help.

“With autism, clients have a hard time putting themselves in others’ shoes, so group is a great way for them to hear from the mouths of peers [and] hear them talk about what they’re going through,” Hull says. “Maybe someone [in group] had to ride a different bus than usual. It was terrifying at first, but they were OK and actually ended up talking to the person they sat next to.”

The group format, in which participants take turns offering comments, can model and teach the back-and-forth “tennis match” that is the basis of healthy conversation, Hull adds. It can also help clients learn to tolerate and listen when someone is talking about a subject that doesn’t interest them — a circumstance that previously would have triggered their fight-or-flight response and caused them to exit the situation.

Hull often has group participants speak for five minutes each on something they are passionate about. Afterward, he urges all of the group members to ask questions or make a comment about what was said.

“This is really hard with autism. If they don’t like something, it’s utterly meaningless to them,” Hull says. “This has them put themselves in others’ shoes and imagine how it’s like [something that they] like. This can transfer to social situations outside of group, such as a dinner party where other people are talking about whatever. Can you listen and learn something? It’s teaching their brain to overcome fear and learn a new normal. Everyone is scary when you first meet them, but you can do it. If you can do it in group, it’s the same as at school or a new job.”

Hull also uses video games in sessions as a way for participants to learn about group dynamics, leader/contributor roles and overcoming frustration (see sidebar, below).

It is important to prepare individuals with social anxiety for the group setting as much as possible ahead of time. Hull often shows clients the group room at his office (or emails them photos of it) and explains the format and what sessions will entail before they join group counseling.

“I walk back to the [group] room with the client and their caregiver before a group session so they can see it,” Hull says. “I explain, ‘Everyone who is coming here feels what you feel, and they’re all struggling with this.’”

When new clients join a group, he never makes them introduce themselves or speak right off the bat. He also allows them to bring anything that might boost their courage, such as a favorite stuffed animal or even a parent in the cases of younger clients. With social anxiety, it is important to allow clients to warm up and contribute at their own pace, he says.

“I can see group members five or six sessions in and they haven’t talked yet. I never stop trying to get them to engage or open up, even if all they can do is a head nod or fist bump,” Hull says. “[I emphasize that] I’m just happy they can be in the room.”

Hull acknowledges that group counseling isn’t a fit for every client who struggles with social anxiety. Social anxiety falls on a spectrum, and for some clients, the disorder is so severe that a group setting would be too much, he says. It is important to continue individual sessions with these clients, with group counseling becoming a possible long-term goal for some of them, he says.

When it comes to group counseling and social anxiety, it is crucial to take things step by step and to celebrate little victories, Hull emphasizes. With clients on the autism spectrum “the victories are fewer and far between,” he acknowledges, “but when they happen … you feel like you’ve won the Super Bowl.”

The long haul

Hull says that counselors should view social anxiety as a process rather than something to “fix.” Neuroscience tells us that the brain responds better to slow and steady change rather than forced or rushed adaptation. This is especially true for clients who struggle with social anxiety in addition to neurodevelopmental issues, past trauma or other mental health diagnoses, Hull notes.

Something else that counselors should avoid is projecting their assumptions onto clients with social anxiety. Just because the counselor went to prom as a teenager doesn’t mean that should automatically become a goal for every teenage client or, for that matter, even be considered the rite of passage that it once was, Hull says.

Counselors should really get to know their client’s world first before doing anything else, Hull says. “Avoid putting your agenda or perceptions on a client. We often see the potential in our clients, and it’s hard not to say, ‘Just do it!’ It can be discouraging and slow going at times, [but] be patient.”

 

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Technology and social anxiety: A double-edged sword

We live in a world where a person can text a happy birthday message to a friend, order a week’s worth of groceries for delivery and apply for a loan with the click of a button — all without having to speak to another human.

So, when it comes to social anxiety, technology can be a double-edged sword. Clients can certainly use it as an easy escape route to avoid social situations. At the same time, mental health practitioners can use it as a teaching tool with clients and as a bridge to overcoming long-held behavioral patterns.

“As great as it can be, technology can be part of avoidance,” says Robin Miller, a licensed professional counselor (LPC) who specializes in treating adults with anxiety. “Learn how to have conversations [about technology]. Make sure a client isn’t too reliant on it and unable to do things in a more social, direct way.”

Miller suggests that professional clinical counselors ask clients about their technology use at intake along with other questions about avoidance behaviors. Counselors can prompt clients to provide examples of situations where they feel most anxious and then listen for overreliance on technology, such as texting to ask someone out on a date or habitually using the self-service checkout line when shopping.

Social media can also exacerbate the assumption of judgment that often accompanies social anxiety, Miller adds. Clients who see photos and posts about friends’ and peers’ vacations, children or happy life events may come to believe that their lives pale in comparison.

Elizabeth Shuler, an LPC and an international school counselor, agrees. She says social media has created a new layer of social anxiety “centered around likes, comments and followers” in many of the adolescents with whom she works.

“I see students every day who are upset — to the point of panic attacks — that they’ve lost followers or that no one is liking their Instagram pictures. Instead of being afraid of being seen as stupid, these kids are afraid of not getting likes. It is a whole new world of judgment that has been unleashed on our teens, and it is taking a toll,” Shuler says. “However, many people who find face-to-face interaction intimidating can benefit from starting with digital interactions. Using texting, video and other digital means of conversation can help people with social anxiety learn social skills and give them a chance to practice new skills in a safer, lower stakes environment.”

Kevin Hull, a licensed mental health counselor in private practice, finds technology — specifically, video games — a natural tool for working with his young clients, many of whom are on the autism spectrum. In group counseling, Hull uses multiplayer games such as Minecraft to introduce clients to interacting and working together in a way that provokes less anxiety than face-to-face conversation might. Group members take turns being a “foreman” and leader in Minecraft sessions. The group learns to communicate and work together while dealing with frustrations and the nuances of the leader/contributor roles. “If technology wasn’t there, these kids would be even more regressed,” Hull says.

Conversations about technology use can also be an important part of social skills training in counseling, Hull adds. For example, young clients might claim that they are “dating” someone when they are actually just texting or playing video games together over the internet.

Hull often talks with clients about how texting is a good place to start communication but that it should not become their be-all, end-all. He’ll say to the client, “It’s great you’ve made a connection through texting, but what about the next level? Your brain’s process to communicate in text is the same as in speech. It’s just a different route.”

— Bethany Bray

 

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Social anxiety and college

The transition to college — leaving home, living with a roommate and establishing a new social circle, all while navigating academic responsibilities — doesn’t have to be paralyzing for students with social anxiety. Read more in our online exclusive, “Heading to college with social anxiety.”

 

 

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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.

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.

Facilitating support groups for caregivers

By Brooke B. Collison July 8, 2019

The 40 million adults in the U.S. identified as caregivers often find themselves overwhelmed, lonely and depressed. They provide care on a part-time or full-time basis for individuals — usually family members — who, because of health or other reasons, need assistance with activities of daily living. Facilitated groups can provide a nonjudgmental framework for caregivers to find understanding and support from others who are in similar situations. Support groups can be self-sustaining, but they function best when a professional counselor or trained facilitator assists group members with their processing.

A gentle but convincing nudge from my spouse started my volunteer work as the facilitator of a caregiver support group six years ago. I continue to serve caregivers in that role today. My experience as a facilitator has allowed me to make a contribution in my retirement, and I encourage other counselors to explore the same possibility.

Enormous variability exists in caregiving situations, but common among them are conditions that are of high concern in aging populations: dementia, Alzheimer’s disease, chronic illness and other age-related deterioration. The three individuals my wife pointed out to me in church that Sunday morning had become full-time caregivers of spouses with Alzheimer’s disease. My spouse said to me, “They need a group. You should do something.”

The first group started with a direct invitation from me: “Would you like to get together with some other caregivers to have a place to talk?” I was met with quick affirmative responses from two of the three people I approached, and they were soon joined by a few others who heard something was beginning. Over time, the group grew to a dozen members, with some joining and some leaving as caregiving situations changed.

Nine deaths of care receivers occurred during the first three years before the caregivers decided to dissolve the group, having worked through the stresses and strains of caregiving, as well as the agonies and life-change issues of death. Among the caregivers in that first group were spouses, adult children, relatives of care receivers, and an employee of a care center. Although the medical and physical issues of care receivers were varied, the issues of being a caregiver seemed universal.

The support group was probably therapeutic, but it was not therapy. Although I have been a licensed counselor, I was the facilitator for the group, not the therapist. People entered the group voluntarily, and there was no contract that described my behaviors, philosophy or approach. I had retired as a counselor educator and did not renew my counseling license. So, I would clarify to new members that my role was to facilitate the discussions in the group. I also stated that I had no expertise in any of the medical issues being experienced by the care receivers. I explained that, as the facilitator, I would help manage the discussion, ask questions to clarify issues and, if I felt it necessary, remind members of the few general ground rules they had established for themselves: Treat personal situations and conversations with respect, don’t dominate, listen, and accept another person’s feelings and emotions as legitimate.

I do have a philosophy about support groups. I believe that most of these groups can develop to a point where they can manage their own issues and in-group communication. However, I saw part of my role as being somewhat protective of vulnerabilities among group members. If a member expressed strong feelings that might be contrary to the beliefs of another member, I would monitor critical responses. For example, if a caregiver expressed anger at a spouse or partner — “He makes me so mad when he …” — I would listen for the “You shouldn’t feel that way” response. This seldom happened, but when caregivers are living by the “in sickness and in health” vow they took at the beginning of their marriages, they can have a set of values that discourage anger toward or criticism of a spouse.

My belief is that the primary value of caregiver support groups is to provide a place where caregivers can give voice to stressful experiences, strong feelings and personal frustrations in the company of others who, ideally, give verbal and head-nod agreement with the issue rather than criticism or value-laden responses that only make these difficult feelings intensify. In short, caregiver support groups should provide what most people in the caregiver’s larger circle cannot give — authentic empathic understanding.

There have been times during the life of caregiver groups when I moved from the role of facilitator to member. I became a caregiver when my spouse broke her hip when we were traveling out of state, resulting in surgery and several months of recovery. At one session, I moved from “my spot” in the circle to a different chair and announced, “I’m a member today, not the facilitator.”

I proceeded to share an experience in which I had become quite upset over a huge mix-up in communication with my spouse that had left each of us very angry with the other. At the time, I saw our inability to clearly communicate — both in sending clear statements and in not understanding statements — as a scary image of what our future might become as we grew older. The communication mix-up, which became funny in time and with perspective, loomed at the time as a grim picture of a possible future. Members of the support group heard my story, shared their similar concerns, and accepted my worries. When I shared the same episode with other friends, it drew none of the same empathic understanding.

In a second major block of time in the same support group, I became more member than facilitator after my spouse was diagnosed with an untreatable brain cancer and lived only three more months. I remained in the group as a member, and another person took up the facilitator role very effectively.

Several kinds of support groups can be found in most communities. I prefer a noncurricular support group. In these groups, discussion topics emerge from the issues that caregivers bring to the sessions rather than from a predetermined agenda. Many support groups, especially those established for a fixed number of sessions, operate from a curricular base — sometimes even with a textbook — and have specific topics identified for each session. Other support groups may become more instructional in format. I believe the noncurricular support group provides the best opportunity for members to talk about the critical concerns and issues they have in the caregiver role and to find the greatest empathic understanding among a small group of people who share somewhat similar life situations.

Caregiver issues

In the caregiver support groups I have facilitated, members have raised a broad range of issues, including:

  • Loneliness
  • Depression
  • Role reversal
  • Becoming an advocate for the care receiver’s medical and social needs
  • Preparing for the care receiver’s death
  • Money/estate issues
  • Sexuality
  • Respite
  • Handling inappropriate questions and responses from others
  • Lack of patience
  • Anger
  • Relationship changes
  • Asking for, accepting, giving and refusing help
  • Decision-making for self and others
  • Concerns for their own health
  • Conflict with parents/siblings
  • Change in social supports
  • Moving the care receiver to a care facility and being an advocate for
    them there

I will comment on a few of these issues more specifically to demonstrate the value of a noncurricular caregiver support group.

Loneliness characterizes the lives of most caregivers to a certain degree and becomes extreme for some. Becoming a caregiver means that a person’s world changes. Day-to-day employment, recreational and social activities no longer exist for that person in the same way. In cases in which the care receiver’s dementia or other cognitive dysfunction begins to increase, the caregiver discovers that the person, although still physically present, begins to disappear. Loneliness becomes a way of life, as the years of sharing spirited discussions each morning over newspapers and coffee turn into coffee and silence. It isn’t uncommon in a support group to hear someone say, “She’s/He’s just not there.” The support group becomes a loneliness antidote for many members.

Depression is another common topic in caregiver support groups. More than a third of long-term caregivers experience depression, according to surveys reported by AARP. Caregivers might not use the word “depression” as they talk, but the behaviors and emotions they discuss often reflect that condition. In several group sessions, after a member has talked about depressed status, I have heard other members respond along the following lines: “I was feeling that way after my wife was at home for two months, and my physician labeled it as depression. I’m still on a prescription for antidepressants, and I think it’s perfectly OK to be on the pill.”

Role reversal happens in some fashion for nearly all caregivers who have had a long relationship with the care receiver. Couples who have been together for years and have fallen into clear divisions of responsibility around money management, food preparation, driving, decision-making and other tasks will discover that either physical or mental limitations force role changes. For example, the partner who never wrote a check finds that checks, credit cards, bills, tax preparation and all other money matters now fall under their domain. The person’s reaction to this can be either positive or negative. Being the fiscal manager may give the partner feelings of responsibility and control that they have not had before, or it can be experienced as an overwhelming burden that leaves the person feeling totally incompetent. Discussion of the effects of role reversals can be quite revealing to self and to others. If one partner who seldom drove the car because the other partner was extremely critical is now forced to become the driver — only to discover that the criticism from the nondriving care receiver only increases — relationship stress will multiply.

Lack of patience has been voiced by nearly every caregiver with whom I have had a group experience. As the person they care for starts to slow down physically or as their daily living abilities begin to disappear, caregivers see their daily load increasing, leaving them with less and less time to manage everything that needs to be done. Caregivers will often say their lack of patience is mixed with anger, even when they know it takes the care receiver longer to do nearly everything or that tasks and functions are forgotten or items misplaced. “It now takes 45 minutes to get from the house to the car, and I can feel my anger increasing with every minute. It makes us late for every appointment, and I have to start earlier and earlier for everything we do.” This statement brought unanimous head-nod agreement from an entire group. The discussion shifted to the resulting feelings of anger and loss, then moved into individual strategies for handling impatience and increased time requirements.

Becoming an advocate is a role that some people relish and others avoid. Caregivers are generally thrust into the role of patient advocate with the medical system, the care facility complex, and their surrounding social system in general. Frequent support group discussions have begun with a member telling their story of the previous week’s battle with some element of the complex that serves their care receiver. Sometimes these stories are ones of frustration, feelings of helplessness and lack of needed information. At other times, the story might emerge as a powerful feeling of accomplishment: “Yesterday, I met with the administrator of the assisted-living facility and demanded more attention to medication schedules.” These are moments for groups to celebrate, especially when caregivers who describe themselves as hesitant to challenge authority relate successful actions on behalf of their care receiver. Sometimes, when a discouraging episode has been shared, other members have related to the same issue or provided inside information gleaned from their own trying times. Some have even volunteered to accompany the caregiver to the next appointment.

Respite is labeled by experts as one of the most essential elements of caregiver health. As a topic in a support group, discussions frequently focus on how time away, or relief or respite care, would be appreciated. Simultaneously, caregivers will talk about how respite or any form of time away is impossible. This is frequently tied to the personal belief that the caregiver is the only person who can or should fulfill the task of giving care.

Help becomes a common discussion topic in one of several forms: Where do I get help? How do I ask for help? How do I turn down help? Embedded in many of these discussions are personal core values about what giving or receiving help really means. It is one of those topics where it would be easy for a facilitator to slip over into a therapist role. When caregivers describe how it is essential that they be the one who does everything and how impossible it is for them to accept help with any of their caregiver duties, the natural tendency of the trained therapist is to probe or confront or interpret in order to explore parental and other messages about help. It is also one of those situations in which group members may step in with their own illustrations of what help means, where their core values about help came from, and how their beliefs about help either facilitate or inhibit their functioning as caregivers. In staying away from my therapist tendencies to remain a facilitator, there are times when I can smile later and say to myself, “The group is doing what a good group does; they don’t need me to be the therapist.”

Information needs are high when someone first takes on the caregiver role. In early stages, they may be bombarded with pamphlets from their physician about specific diseases, friends may tell them about books to read, and technologically informed caregivers may search the web for sources. New caregivers are often directed to information support groups; medical facilities may offer groups for individuals with similarly named conditions. I find these groups helpful during the early information-gathering times, but their helpfulness diminishes when the caregiver gets deeper into the caregiving experience and discovers that information is important but not enough. It is more valuable for the caregiver to have a place where they can say, “My life is slipping away, and I don’t know what my future will be,” with six or seven people nodding in agreement. Then one of them says, “Yes, some days I don’t have anything that resembles my life before.”

Other issues common in support groups include concerns about money because long-term illness is expensive. If other family members are involved, conflict with siblings or other relatives is inevitably a cause of stress for the caregiver. Sexuality is usually discussed in the group relative to hygiene and physical care by others, but on more than one occasion, caregivers have dug in to issues of appropriate and inappropriate sexual behavior in care facilities. In a support group, caregivers may find an environment where they can talk about impending death, even anticipating relief when it comes. Often, caregivers will agonize over the decision to place their loved one in a care facility, then have additional agony with second thoughts and regret after the decision has been made, even though the decision will be described as “the right thing to do.”

Support group procedures

I believe the best way to create a caregiver support group is by invitation. Within any group of older people, it is likely that some will be serving as caregivers. Over time, that number will increase. (AARP provides good summaries of this trend at its website, aarp.org; the organization’s reports and resources are easily accessible by typing “caregiver” in the search field.) Posting announcements of a caregiver support group will attract a few people, but many people are reluctant to attend without a direct invitation.

Support groups function best when there are enough people present for good discussion but not so many as to restrict individual participation. My ideal numbers range from eight to 12 participants. I have worked with both larger and smaller groups that seemed effective, however.

Groups have a beginning and an end and can be announced as such. The open-ended entry and exit group can go on for years; facilitators need to be clear about what they are agreeing to do when they begin a group with no clear end. Ending a group and then resuming later with the same members can be effective. This can also serve to ease the transition of new members in and old members out if they choose to leave. I strongly encourage some kind of summary or ceremony when group members depart. Likewise, I urge groups that decide to end to develop a concluding summary and ceremony.

Caregiver groups, by the very nature of what brings people to the group, will morph into grief groups. In my experience, people generally wish to remain with their caregiver group rather than shift to a separate grief recovery group because of the close relationships they have formed and the comfort that comes from being with people who know their story. As group membership begins to reflect more people whose care receiver has died, it does make it more difficult for new members to join.

Volunteer versus paid facilitation is an issue for many counselors. My participation is as a volunteer. In my community, support groups exist that are tied to medical or service agencies in which the facilitator might be a paid employee. There might be instances in which insurance would cover the cost of an ongoing support group, but this is not as likely for an open-ended group as it is for a fixed-length program.

Counselors in private practice could offer support groups for which members would compensate the facilitator. Under those circumstances, members could enter the group in the same way they would enter counseling sessions — with a contractual understanding of the role of the counselor who is operating with a prescribed set of ethics and an appropriate license.

I believe it is important for group facilitators to have a person they can go to regularly to discuss issues that arise for them in the facilitation role. In the same way that we expect counselors to have clinical supervision, facilitators need to seek this support. I get this through occasional coffee sessions with a friend who is a clinician.

I urge counselors to find or to create support groups that make use of the facilitation skills that counselors possess. Caregivers in their communities will be the beneficiaries. The service meets a critical need, and the satisfaction that facilitators will experience is beyond measure.

 

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I’d like to thank Bob Lewis and all the other caregivers over the years who have taught me what I know about support groups. I appreciate the stories and feelings they have shared and for the support they have given each other in such meaningful ways.

 

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Brooke B. Collison is an emeritus professor of counselor education at Oregon State University. He is a fellow and a past president of the American Counseling Association. For the past several years, he has served as a facilitator for caregiver support groups as a volunteer activity in his retirement. Contact him at BBCollison@comcast.net.

 

 

Letters to the editor: ct@counseling.org

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

 

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

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.

 

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 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.