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Wellness

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.

 

The counselor’s role in assessing and treating medical symptoms and diagnoses

By Jori A. Berger-Greenstein April 4, 2018

Take a moment to imagine the following scene, with you as the protagonist: A few days ago, you woke, went for a run, had breakfast and headed to work, where you attended a committee meeting. The next thing you remember is lying in a hospital bed and being told that you had a stroke. You seem unable to move or feel one of your legs.

You are in a double room with an elderly man who has had many relatives and friends visit, although he seems not to be doing well. You’re not sure, however, because you feel foggy. Is this a side effect of the medication they keep giving you?

You are dressed in a hospital johnny and confined to bed. A nurse checks your vital signs on the hour, often waking you when you’re sleeping. An intravenous tube in your arm is connected to a bag with some sort of liquid in it, and you are hooked up to monitors, although you’re uncertain of what they are monitoring. Beepers sound regularly, prompting the nurses to come check you, look at the monitors or change out the bag.

A doctor visits in the mornings, along with a group of medical students, reminding you of Grey’s Anatomy, complete with looks back and forth and eye-rolling. They talk among themselves as if you aren’t there, using medical jargon that you don’t understand. Your family members are anxious and tearful. You hear them talking to the doctor about transferring you to another facility because your insurance won’t continue to cover your stay in the hospital. You also hear your spouse on the phone with relatives who live across the country but want to come see you.

As the patient, how might you be feeling? What might you be thinking?

Now imagine that instead of being the patient, you are a mental health provider called in to assess the patient for depression. How might you respond?

The above scenario and others similar to it are commonplace for many providers who operate in the field of behavioral medicine, which the Society of Behavioral Medicine defines as the “interdisciplinary field concerned with the development and integration of behavioral, psychosocial and biomedical science knowledge and techniques relevant to the understanding of health and illness, and the application of this knowledge and these techniques to prevention, diagnosis, treatment and rehabilitation.”

As recognition of the psychological and behavioral factors involved in medical illness has increased, so has our ability as mental health counselors to serve a valuable function in patient care. Providers and researchers alike now recognize the importance of approaching health care more holistically rather than compartmentalizing medical versus psychological well-being.

Understanding context

Primary care providers, the first stop for most people’s health-related complaints, operate under ever-increasing pressures to provide care for more people in less time. The average visit lasts 10 to 15 minutes, with the goal of assessing presenting symptoms (typically while simultaneously entering patient information into a computer system) to ascertain their cause and thereby provide information about how to treat them. There often isn’t time to gather the context of these symptoms, increasing the likelihood that important details can be missed. Likewise, there isn’t sufficient time to fully discuss the pros and cons of treatment options, the potential barriers to treatment and whether a patient is willing or able to follow through on the treatment recommendations.

In contrast, mental health providers often have the luxury of coming to understand patients/clients more fully. This includes understanding and appreciating the contexts in which patients/clients find themselves, understanding how these individuals are coping and making meaning of what is happening, and forming a trusting relationship with them, which is consistently demonstrated to be predictive of adherence to care and improvements in health-related parameters.

As Thomas Sequist, assistant professor of health care policy at Harvard Medical School, stated in a New York Times article in 2008, “It isn’t that [medical] providers are doing different things for different patients, it’s that we’re doing the same thing for every patient and not accounting for individual needs.”

It can be said that medical providers are trained to identify and treat symptoms in order to identify disease so that a patient can be effectively treated — which is, in fact, their role. In contrast, mental health providers are trained to treat people and illness — illness being one’s experience of disease rather than just a compilation of symptoms or diagnostic labels.

The process of assessing for mental health symptoms

A variety of mental health conditions are characterized by symptoms that overlap with those attributable to medical conditions. For example, symptoms of an overactive or underactive thyroid mimic anxiety and depression, respectively. Psychosis can mimic neurological conditions, mood disorders can mimic endocrine disease, anxiety can mimic cardiac dysfunction and so on.

Through training mental health clinicians to identify symptoms that may indicate a medical cause and knowing how to assess for the possibility of a medical workup, we can make earlier referrals for medical care. This, in turn, helps us to identify diagnoses more quickly, leading to easier/more efficacious treatment and better validating concerns.

One’s cultural identity and the resonance of cultural norms are also important to assess and monitor. For instance, a patient may be reluctant to engage with an English-speaking provider, may have a vastly different conceptualization of illness as punishment (in stark contrast to the Westernized biopsychosocial model) and may need validation for his or her reliance on faith and spirituality.

Collaboration

Collaborating as mental health clinicians directly with medical professionals toward the common goal of helping those who need our care can be invaluable. Examples include ruling out mental health disorders, identifying appropriate treatments in the case of comorbidities, providing emotional support to patients who have been diagnosed with a medical disorder and supporting physicians who may be overwhelmed. For instance, medical treaters may not know or understand the presentation of symptoms associated with trauma or the intricacies of providing trauma-informed care.

Being knowledgeable as mental health clinicians about medical-related symptoms, the language and jargon of medicine, and strategies for navigating the medical system provides us with critical credibility. This credibility can make or break our ability to collaborate as mental health clinicians.

Providing care

At its best, behavioral medicine functions as a prevention-focused model with three levels of care:

1) Primary prevention refers to preventing a problem from emerging to begin with. Examples of this might be establishing obesity prevention programs in public schools for young children or working with high-risk families to promote safety practices. The idea is to work with groups that may be more vulnerable to risks at some point in the future and to prevent those outcomes from occurring.

2) Secondary prevention involves working with people who have developed a problem of some sort, with the goal of preventing it from worsening or becoming a larger problem. Examples include working with people who are prehypertensive in order to prevent hypertension and subsequent cardiovascular disease or stroke, and working with people with HIV to increase their adherence to antiretroviral medication to reduce viral load, making them less infectious to others and providing them with more healthy years of life.

3) Tertiary prevention refers to helping people manage an already-existing disease. This might involve increasing quality of life for people enduring a condition that won’t improve, such as a spinal cord injury, multiple sclerosis or late-stage renal disease, and supporting people in the later stages of a disease that is imminently terminal.

Transtheoretical model (stages of change)

Although mental health clinicians may be familiar with efficacious interventions for a given condition, we may not be perceived as credible if we do not understand and respect the client’s/patient’s motivation. No mental health provider’s repertoire is complete without an understanding of the transtheoretical model and how to utilize it to increase an individual’s motivation for positive change.

Assessing where a client/patient might be in the stages of this model (precontemplation, contemplation, preparation, action, maintenance) helps us to better target our interventions in a respectful way by taking context into consideration. Clients/patients in the precontemplation stage might benefit most from education and are less likely to be receptive to recommendations for lifestyle changes, whereas those in the action stage may not need as much of an emphasis on motivation. For a thorough description of the transtheoretical model, I would refer readers to William Miller and Stephen Rollnick’s seminal work, Motivational Interviewing: Helping People Change.

Concrete needs and specific skills

The majority of causes of death and disability in the United States are those caused or treated, at least in part, by behavior. Nationally, the top 10 causes of death, according to the Centers for Disease Control and Prevention (2015), include cardiovascular and cerebrovascular disease, cancer, pulmonary disease, unintentional injuries, diabetes, Alzheimer’s disease and suicide. Changes in lifestyle, knowledge/education and interpersonal support can be successfully utilized as part of all three levels of prevention. In fact, these are areas in which mental health providers can be extremely valuable.

Primary prevention: Data suggest that the single most preventable cause of death is tobacco use, which can dramatically increase the risk of developing cancer, pulmonary disease and cardiovascular disease. Comprehensive smoking-cessation programs can be quite effective in managing this, as can education to prevent young people from initiating cigarette use.

Sedentary behavior (and, to a lesser extent, lack of exercise) is also strongly associated with health problems, perhaps most commonly cardiovascular disease and cancer. Concrete strategies for introducing nonsedentary behaviors (using the stairs, standing up once an hour, walking) can be incorporated into one’s lifestyle with less effort than a complex exercise regimen.

Getting proper nutrition, practicing good dental hygiene and consistently wearing sunscreen, helmets and seat belts are other examples of primary prevention in behavioral medicine. Motivating people who have not (yet) experienced the negative consequences of their risk behaviors is an approach that mental health providers are trained to provide.

Secondary prevention: The rates of obesity have risen dramatically in the past decade and are associated with a wide variety of serious medical complications, including diabetes, cardiovascular disease, stroke and cancer. If treated effectively, the risk of such complications can be reduced significantly. Examples of interventions found to be useful include aerobic exercise, dietary change (such as adhering to a Mediterranean diet and managing portions) and monitoring weight loss.

Although the specifics of these interventions may be most appropriately prescribed by dietitians and physical therapists, mental health providers can add value by helping to increase clients’/patients’ motivation and adherence, providing more thorough education about recommendations and collaborating with other providers.

Tertiary prevention: Spinal cord injury, most often caused by motor vehicle accidents, falls or violence, can have a devastating effect on a person’s life. These injuries are not reversible, but mental health providers can prove valuable in tertiary prevention efforts. These efforts might involve providing existential support; helping patients to navigate the medical system and ask for/receive support from significant others; and identifying strategies for improving quality of life and accessing tangible resources to sustain some aspects of independence.

Getting started

So, how might clinical mental health counselors “break into” the system? The ideal is an integrated care model in which mental health providers are colocated within the medical setting. This serves a dual function of facilitating mental health referrals and making it easier for patients/clients to see us because we’re just down the hall or up a flight of stairs from the medical providers. It also ensures that we remain visible to medical providers and allows for us to easily demonstrate our value.

Short of this, and for those who are less interested in focused work in behavioral medicine, the following suggestions may be helpful:

1) Attend trainings. This is a crucial first step before mental health counselors can ethically market themselves as being knowledgeable about behavioral medicine. As an example, with rates of diabetes increasing, and associated adjustment and psychological sequelae common, learning all you can about the disease and strategies for managing it provides you with some expertise and a valuable referral option. This is consistent with current recommendations for branding a practice.

2) Develop a niche. Your services can be all the more compelling if you have developed a niche for yourself that fills a gap. Research your area and the specialties that mental health providers are marketing. Is there something missing? For instance, many providers may be offering care for people who are terminally ill, but are there providers specializing in working with young people in this situation? Are people who specialize in working with pediatric cancer also advertising services to treat siblings or affected parents?

3) Being mindful of your competence and expertise, connect with medical providers and let them know that you are accepting clients. For instance, if you work with children or adolescents, consider reaching out to pediatricians. Research consistently finds that the only linkage to care someone with mental illness may have is through his or her primary care physician. Providing these physicians with literature about your services makes it easy for them to pass along your information to anyone they think may benefit. Mental health counselors can connect with medical providers via personal visits to physicians’ offices or through direct marketing to professional organizations. Note that approaching small practices may be the better option because they are less likely to already be linked with another service (hospitals often have their own behavioral health clinics/providers).

4) Connect with specialty care providers. These providers tend to have greater need of mental health professionals who are familiar with a given diagnosis.

5) Don’t be afraid to contact a medical provider treating one of your clients. This can provide a means for collaborative care and could also serve to gain you credibility, while indicating that you are glad to take referrals. Clearly, this should be done only if clinically indicated and only with the client’s permission.

6) Finally, be prepared to describe your experience, training and competency areas in a brief fashion. In the busy world of medicine, time is quite valuable. Mental health providers’ skills in waxing poetic can get in the way of communicating the essence of what we want to get across.

Ethics

This article would be incomplete without a mention of ethics. Behavioral medicine is a field rife with ethical concerns. Perhaps the most salient of these is competence. From an ethical lens, it is critical that we, as mental health counselors, recognize the limits of our competencies — that is, we are not trained in medicine and thus cannot ethically diagnose a medical condition, recommend treatments that could be potentially harmful or assure patients/clients that medical evaluations or treatments are unnecessary. All of these actions require the input and monitoring of medical treaters, who can guide our efforts in care. Patients/clients also need to be clearly informed of both our benefits to and limitations in their care. The world of medicine changes rapidly, and the half-life of training in medicine and medical care is short. Ongoing education is critical.

Let’s return to the scenario described at the beginning of this article. The shared goal for all providers — medical, psychological and other — is to provide efficacious and meaningful care in a way that improves the patient’s health and quality of life. By utilizing our respective areas of training, competencies and strengths, we can better understand the context of symptoms, which can guide our care. This is the cornerstone of providing ethical care.

 

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

Jori A. Berger-Greenstein is an assistant professor at the Boston University School of Medicine and a faculty member in the mental health counseling and behavioral medicine program. She is an outpatient provider in adult behavioral health at Boston Medical Center, where she serves on the hospital’s clinical ethics committee. She also maintains a private practice. Contact her at jberger@bu.edu.

Letters to the editorct@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.

Behind the book: Neurocounseling: Brain-Based Clinical Approaches

Compiled by Bethany Bray February 20, 2018

The influence of neuroscience on the counseling profession is growing. So much so that the American Counseling Association has an interest network of members devoted to its exploration and discussion.

Neuroscience can be both a tool — one of many — in a counselor’s toolbox and a game-changing way to conceptualize clients, conduct assessments and select interventions, write Thomas A. Field, Laura K. Jones and Lori A. Russell-Chapin in their new book Neurocounseling: Brain-Based Clinical Approaches (published by the American Counseling Association).

“Neuroscience can help counselors understand how relationships are forged, leading to deeper and more meaningful working relationships with clients; recognize the persisting impact of systemic barriers such as oppression, marginalization and trauma on clients’ ability to achieve their goals; and take a wellness and strengths-based perspective that serves to empower clients and increase optimal performance,” they write in the book’s preface. “In other words, neurocounseling is commensurate with the orientation and identity of the counseling profession.”

Field is an associate professor in the master’s counseling program at the City University of Seattle; Jones is an assistant professor at the University of North Carolina at Asheville; and Russell-Chapin is professor of counselor education at Bradley University in Illinois. Counseling Today sent the trio some questions, via email, to learn more.

 

Q+A: Neurocounseling

(Responses written individually as indicated; some responses have been edited, including for length)

 

Besides your book, what resources do you recommend for counselors who want to learn more about neurocounseling?

Lori Russell-Chapin: We are learning more about the fascinating brain every day through research and brain scanning. Counselors need to know as much as possible about the brain, especially as it relates to the skills of counseling. The very first thing helping professionals can do is refresh their knowledge base and skills. Take a course or workshop on neurocounseling. That material is out there. At Bradley University, there is an online course called “Neurocounseling: Bridging Brain and Behavior.” Perhaps readers might have a desire to even take an introductory course on human anatomy and physiology. Almost any university will offer this course. Even if you took a similar course years ago, take a new one. So much has changed in the last decade. Attend any ACA Conference and participate in the many workshops scheduled on neurocounseling. The number has tripled in the last 10 years.

Decide what aspect of neurocounseling interests you, [and] then ask colleagues for potential courses to take, from heart rate variability to biofeedback or neurofeedback. Many excellent for-profit corporations are offering these biofeedback and neurofeedback courses.

Of course, join any of the professional networks that have been created to connect with others who have similar interests: ACA Neurocounseling Interest Network; AMHCA (American Mental Health Counselors Association) Neuroscience Interest Network and ACES (Association for Counselor Education and Supervision) Neuroscience Interest Network. At the ACA conferences, these three groups join forces to connect and share information.

 

In the preface, you write that neurocounseling is “commensurate with the orientation and identity of the counseling profession.” Can you elaborate? How do you feel neuroscience is a good fit for professional counseling? How are counselors particularly suited to adopt its principles into their work?

Thom Field: Counseling has been defined as “a professional relationship that empowers diverse individuals, families, and groups to accomplish mental health, wellness, education and career goals.”

Neuroscience supports and strengthens the counseling profession’s values, as reflected in the above definition:

1) The relationship takes precedence.

2) Diversity is affirmed and actions are taken to modify the societal conditions and environments that cause dysfunction.

3) Wellness and mental health are as much a focus of intervention as remediating psychopathology.

4) A person’s strengths and challenges are conceptualized within the developmental context in which they occur.

First, neuroscience has and can provide information to us about what conditions are most important for a therapeutic relationship to be established. Information about client neurophysiological responses in the counseling room can help us understand what helping behaviors are facilitative, such as establishing safety and security. Chapter 5 of our book, written by Allen Ivey, Thomas Daniels, Carlos Zalaquett and Mary Bradford Ivey, is instructive in this regard. While theories of effective relational characteristics exist (e.g., interpersonal neurobiology, polyvagal theory), we believe more research is needed in this regard.

Second, epigenetics provides rich information about the neurophysiological impact of systematic marginality, oppression and trauma. Kathryn Douthit’s chapter on the biology of marginality (chapter 3) and Laura Jones’ chapter on traumatic stress (chapter 4) provide an excellent overview of this topic.

Third, neurocounseling supports the importance of adequate sleep, diet, exercise, social involvement and spiritual engagement in optimal functioning. Ted Chapin’s chapter on wellness and optimal performance (chapter 8) provides an extremely helpful clinical case study that emphasizes what a wellness-oriented neurocounseling approach might look like in practice.

Fourth, neurocounseling emphasizes the importance of understanding the development of the brain and body over the life span. Laura Jones’ first two chapters emphasize how to conceptualize client issues through the lens of neurophysiological development.

Lastly, we would be remiss if we did not mention that the text was organized around the Council for Accreditation of Counseling & Related Educational Programs’ 2016 standards. We believe that principles from neuroscience are relevant and applicable to the eight common core CACREP areas (human growth and development, social and cultural foundations, helping relationships, assessment, research, group counseling, ethical practice and even career development) as well as specialization areas (e.g., psychopharmacology, addiction, etc.).

 

In your opinion, how far has the profession come in understanding and incorporating neuroscience into counseling practice? Is it being readily adopted, or are there counselors who misunderstand it or don’t feel that it is useful?

Laura K. Jones: There is the question of how far has the profession come in incorporating neuroscience into counseling practice, and then there is the question of how far we have come in incorporating neuroscience into the profession as a whole, which are two related but distinct questions.

With regard to the profession, interest in neuroscience has expanded significantly in the past 10 years, since Allen Ivey and Mary Bradford Ivey gave one of the first talks on brain-based counseling at ACA’s 2008 Conference & Expo in Honolulu. One example is simply the number of conference sessions that integrate a discussion of neuroscience. At the 2008 conference, there were only around five that discussed the brain in some manner; at the 2017 conference [in San Francisco], there were not only three learning institutes but 17 educational sessions. This pattern of growth is visible across every sector of the counseling field, including both clinical training and practice areas. The 2016 CACREP standards delineate an increased focus on training in the neurological foundations of client development, well-being, presenting concerns and the counseling process, with over three times the number of references to the application of neurobiology and neuroscience than were cited in the 2009 standards.

AMHCA is also strengthening its focus on neuroscience, not only expanding its training and clinical practice standards in such areas, but also now allocating a section of its flagship journal, the Journal of Mental Health Counseling, to articles detailing the integration of neuroscience into counseling research or clinical practice. There are three national neuroscience interest networks, one representing each of the core organizations (namely ACA, AMHCA and ACES), as well as a new neuroscience virtual meetup group based out of Northwestern University, BRAINSTORM, which has monthly meetings to discuss neuroscience research and translate such research into clinical implications. Each of these groups now has hundreds of members — a significant change from the two pages of handwritten names I collected at the 2013 ACES conference in Denver, which were used to start the first neuroscience interest network within the field.

And this is a trend being mirrored across all mental health professions. As research surrounding the physiological underpinnings and outcomes of mental health struggles continues to expand (the roles of inflammation, the microbiome-gut-brain axis, the endocrine system, etc.), mental health providers are being called to reexamine our conceptualizations of mental health and mental health disorders, and neurophysiology is a significant construct within this new paradigm. Occasionally I will still hear individuals refer to this shift as a “fad,” but that perspective appears to quickly be fading.

One of the cautions, however, is that while there is certainly an ever-growing interest and acceptance within the field, as is often the case with an interest that grows quickly, there is also misinformation and to some degree a misrepresentation and overextension of the science that is also occurring. This is why, from my perspective, one of the especially exciting trends I am seeing in this area within our field is the rapidly growing number of master’s- and doctoral-level students who are eager to gain training in neuroscience. This interest, and subsequently the training of these future counselors and counselor educators, is the catalyst for continued growth and research [concerning how we as a profession can integrate neuroscience into our field in a manner that honors our unique professional identity.

To continue to accurately, ethically and successfully incorporate neuroscience into the profession, we need to enhance our efforts at training counselors and counselor educators in the basic principles of neuroscience and how this information can be applied to our work with clients, supervisees and students. As such, we cannot sustain this interest within the field and our reputation in the larger mental health world without having a body of counselor educators who are accurately trained in neuroscience and able to teach future generations of practitioners and educators.

This is one of my primary interests in this movement and was a significant impetus for me in working on this book. This gets back to the original distinction I made between a growing emphasis in the field versus in clinical practice. Where we see the preponderance of the integration of neuroscience into counseling practice now is in client conceptualizations, psychoeducation, wellness practices, social justice and, to some degree, assessment. Research has also substantiated that psychotherapy has the ability to enhance brain functioning in the alleviation of client symptoms. However, additional outcome-based research is needed within the counseling field in particular to further our understanding of how we can use neuroscience to further substantiate our theories and techniques, as well as build new, more efficacious interventions.

We have made significant progress in the last 10 years, and yet we still have plenty of room to grow, as do the other mental health professions in this area. I am excited to see the continued expansion of neuroscience within our field and counselors become even more established as leaders in neurophysiologically informed research, practice and mental health policy in the future.

 

What misconceptions might counselors have about neurocounseling?

Laura K. Jones: There are a number of common misconceptions that individuals have when it comes to the integration of neuroscience into clinical training and practice. One of the primary misconceptions is that neurocounseling is a new branch of counseling, often likening it to a new theoretical orientation of sorts. In reality, the integration of neuroscience into clinical practice can best be conceptualized more as a metatheory of the clinical process that can be applied to every theoretical orientation.

This distinction has led some individuals to suggest that the term “neurocounseling” is to some degree misleading. Understanding the neurophysiological correlates of clients’ developmental levels, struggles, strengths and progress can all be used to inform and enhance all aspects of the clinical process, from case conceptualization and assessment to interventions and advocacy. It is a layer of information that we as mental health providers can use to enrich our understanding and work with clients. This knowledge of the brain and body can also be used to develop new theoretical approaches, such as neuroscience-informed cognitive behavior therapy (CBT), but it is not in and of itself a separate form of clinical practice.

Another misconception is that integrating neuroscience into our field and practice is just another way of medicalizing the profession. Relatedly, some have voiced fears that it takes too much of a reductionist view of clients and client struggles. Understanding the neurophysiological pathways of addiction, for example, does not negate or diminish the importance of the therapeutic relationship, but it can help us to decrease the internalized stigma some of our clients may have of being weak and, similarly, empower our clients in their own recovery. As another example, take some of the developing theories around depression. Researchers are working to further substantiate the divergent pathophysiology between possible subtypes or phenotypes of depression. This information can be used to help us develop more effective therapeutic approaches for our clients. Neuroscience is not a threat to our professional orientation; if anything, it can be used to strengthen what we uniquely do as counselors.

An additional misconception is that in order to integrate neuroscience into your practice, you need specialized and expensive equipment. Although biofeedback and neurofeedback are growing in popularity, efficacy and accessibility, and can certainly be used as part of informing and enhancing your work with clients, this is not the only way of integrating neuroscience. This is something that I like to really emphasize when discussing the role of neuroscience within the field. You do not need any fancy toys to benefit from all that neuroscience has to offer.

Just having the information related to how the brain and body respond to trauma completely changes the way that counselors conceptualize trauma survivors who are struggling with symptoms of posttraumatic stress. Similarly, knowing how the brain is developing during adolescence not only demystifies the struggles children and parents may face during this seemingly tumultuous time, but also changes how we approach working with individuals during this developmental period. The knowledge in and of itself can simply make us more intentional in our work.

The final misconception is one that is still somewhat debated even among those of us working in this area. I often get the question, “Do I actually need to learn the anatomy or physiology?” My answer to this is always a resounding “yes,” but I certainly do not speak for everyone working in this area. I am not suggesting that counselors need to be experts in neuroscience, but knowing the basic physiology and nomenclature allows counselors to understand the basis behind why a particular approach may be more beneficial for a particular client and be more intentional in that decision. It also allows counselors to continue reading the research that is coming out on a near-continuous basis. What we believe we know about the brain today may very well change tomorrow.

Also, fields that translate “hard” neuroscience research into applied contexts (education, peak performance, counseling, etc.) can at times fall victim to overextending and misrepresenting the original research as they attempt to retranslate other translations of the science. This may sound a bit convoluted, but what I mean is that one practitioner who is well-versed in neuroscience will translate the possible implications of some neuroscientific finding into practical and applied information for their particular field. Then another practitioner in an allied area may take that information and try to reapply the initial implications in a new way to the new field. This is the root cause of a number of the “neuromyths” that are currently circulating and why there are so many “brain training” games available today. In essence, we become too far removed from the actual science.

Our field needs to be able to do some of that translation firsthand and, ideally, build interdisciplinary research teams to collaborate in conducting the research rather than rely on translations from other fields.

One final rationale for training in basic anatomy and physiology is that we are seeing a growing number of integrated care practices and interdisciplinary treatment teams. Having a basic knowledge of the physiology allows counselors to collaborate more effectively with the other specialties and advocate for the best care of their clients.

 

What made you collaborate on a book about neurocounseling? Why do you feel it’s relevant and needed?

Lori Russell-Chapin: There are many neurocounseling experts throughout the United States. By joining forces, we can share this knowledge with so many other professionals who are interested. Integrating the concepts of neurocounseling from our book into my counseling has made me a more efficacious practicing counselor, counselor educator and counseling supervisor. The following short examples are offered to demonstrate why neurocounseling is relevant and needed in our counseling field.

Neurocounseling interventions strengthen the intentionality of counseling. Understanding the brain and its functions make skill selection and strategies even easier. Teaching self-regulation skills such as diaphragmatic breathing or physiological and emotion regulation requires many brain connections to connect together from the prefrontal cortex, the insula and the anterior cingulate cortex. The next time you teach any self-regulation skill, think about all the brain centers you are activating.

Understanding that rapport building and therapeutic alliance is essential to counseling and change is central to the tenets of neurocounseling and counseling. Both rapport and therapeutic alliance create emotional and physiological safety using the vagus system and interoception, helping the body be more aware of its senses. There is nothing more important to clients’ change than rapport and emotional safety.

Even as my clients are introducing themselves to me for the first time, I begin to experience them in a more holistic manner. With that first handshake, I can feel if their hand is cool, warm, sweaty or limp. Each of these symptoms is a clue to a person’s sympathetic and parasympathetic nervous system. If the client’s hand is very cold, then it might be that he or she is anxious, [thus] activating the sympathetic nervous system. I could easily teach diaphragmatic breathing, heart rate variability and skin temperature control to help initiate the parasympathetic nervous system where we are supposed to be most of the time.

Still another neurocounseling example is essential for building healthier neuroplasticity. Because of negative bias and the system’s evolutionary nature to survive, counselors must use our positive reflections lasting at least 10-20 seconds to deepen this change and build positive neuroplasticity. We remember a negative experience almost instantly. To remember a positive experience takes much longer.

Lastly, counselors must better understand that skills such as summarizations assist the client and the counselor to activate the default mode network. This network helps us see the world of self and others in a more comprehensive manner. Identifying the neuroanatomy aspect of our counseling skills allows for more intentionality and strategy in counseling. This is neurocounseling at its best. Then collaborating with others gives greater access to all this knowledge. Working together again offers the best method to expand the depth and breadth of neurocounseling.

 

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To join the ACA Neurocounseling Interest Network, contact Lori Russell-Chapin at lar@fsmail.bradley.edu. For more information, see neurocounselinginterestnetwork.com.

 

 

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Neurocounseling: Brain-Based Clinical Approaches is available both in print and as an e-book from the American Counseling Association bookstore at counseling.org/publications/bookstore or by calling 800-347-6647 x222

 

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

 

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

 

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

 

Understanding the connection between nutrition and mental health

By Robika Modak Mylroie and Rachael Ammons Whitaker January 17, 2018

In recent years, obesity has seized the attention of the medical field and the media. Now our schools are starting to recognize the impact of obesity on mental health. The United States is known internationally for its larger plate sizes, big portions and supersized meals in restaurants. However, we are also witnessing the beginnings of a cultural shift that encourages body acceptance and pushing back from an ideal body type.

At the same time, it may also seem that our society has become obsessed with healthier food options. But do we really understand nutrition? When we see terms and phrases in grocery stores such as organic, humane, low carb, high protein, non-GMO, no artificial coloring/preservatives and natural, it can be overwhelming. Some of these terms can be misleading or confusing. Our society is overmarketed with food slang and undereducated on what food labels mean to nutrition.

School and mental health counselors should be asking themselves how physical health and body acceptance intersect with weight, body mass index (BMI) and mental health. What if a person is deemed to be at an unhealthy body weight but is genuinely OK with his or her body? Conversely, what if this person is not happy with his or her body yet is considered healthy? When it comes to these body issues in children, at what point do school counselors intervene? How do we begin to support childhood social and emotional concerns surrounding nutrition without shining a light on those children who might be in a fragile stage related to their body awareness and image? How do we teach families and school employees to use language that promotes positive body image?

Although most medical journals openly discuss pediatric obesity as a major public health concern, they continually fail to address how to effectively combat such issues. The same statement applies with counselors. We know that childhood weight is a concern, but are we doing enough within our schools? Brain studies show that nutrition plays a role in learning, concentration and mental health in general, so why is it so hard for us to connect the dots?

Let’s explore the disconnect between childhood obesity, nutrition and mental health, and how we, as counselors, can support child nutrition in school settings. Can making the connection between nutrition and social-emotional needs move counselors to collaborate more effectively with other professionals? Counselors should care about what we are feeding our youth during school hours because it impacts our profession directly.

There also needs to be an awareness among parents and caregivers that nutrition is important not only in the school but at home. One of the issues that school counselors face is that not all parents and caregivers are supportive. Even if they are supportive, they may not possess the means to buy healthier food for the home or to prepare meals consistently. Preparation takes time, and not all families have that time to devote. Socioeconomic status, family makeup and genetic issues can also contribute to childhood weight and nutrition levels. For instance, there may be a lack of food in the house because the family cannot afford it, or there may be foods that are high in unhealthy fats and sugar.

Education is key to awareness, but this is difficult when we as counselors are not advocating for changes in school nutrition. We need to educate ourselves and make a connection in our profession between nutrition and mental health.

What we know

Childhood obesity is not a new concern in the United States. Many articles have been published on the health concerns of children who are overweight or obese. Michelle Obama’s “Let’s Move!” campaign brought national attention to the issue. During an open discussion this past spring, the former first lady said, “You have to stop and think, why don’t you want our kids to have good food at school?” During her time as first lady, Obama also hosted the School Counselor of the Year national recognition ceremony at the White House. This begs the question: Why have counselors, and, specifically, professional school counselors, not taken action on this issue?

Unfortunately, if the first lady struggled to implement this agenda, it stands to reason that it might be equally difficult for school counselors to get a foot in the door. Because of the disconnect between counseling and nutrition, it might even seem odd to some people that school counselors should get involved at all. As mentioned earlier, however, there is actually a deep connection between the two. Researchers have shown that poor diet not only leads to physical health problems but also affects brain functioning. Brain studies have shown that what people eat affects not only the social-emotional realm but also academic performance.

In March 2017, Laurie Meyers wrote a cover story for Counseling Today titled “When brain meets body” that discussed the connection between physical and mental health. More specifically, it delved into how thoughts can cause changes in the regulation of cortisol, which can then affect our clients’ physical health. This physical heath-mental health connection is emphasized in the mental health community but not as often in the school community and hardly at all in the medical community.

Why this research matters to us

The World Health Organization’s obesity map shows that as a whole, more than 30 percent of the U.S. population is obese. The Centers for Disease Control and Prevention (CDC) reported that 35 percent or more of adults in Mississippi, Alabama, West Virginia, Louisiana and Arkansas were obese. The CDC also noted that there was no state in the country with an obesity percentage of less than 20 percent among adults.

Mississippi tends consistently to be near the top of the charts for adult and childhood obesity, which is what sparked our interest in pursuing research in this area (both authors are from Mississippi). One question we asked is why a state such as Mississippi, which is rich in farmland and has an abundance of crops and fresh produce, has a prevalence of obese children. Our state should have abundant nutritional food available for families, including for those of low socioeconomic status. Lack of education and what people can afford likely have some connection to obesity rates in Mississippi. Statistics show that education and salary levels are highest in those states with lower obesity percentages. Mississippi ranks last in education statistics among the 50 states.

Healthy food consumption should not be dependent on social status. It should be affordable to all. However, many foods that are healthy and easy to prepare are also the most expensive. According to the website TalkPoverty.org, 20.8 percent of people in Mississippi live below the poverty line. Schools in this state, and in many of the other states identified as “obese and overweight,” may not be able to afford these healthier options in bulk.

This raises other questions. What can we do differently to secure healthier food access in our schools for reasonable prices? How do we partner with local farmers to provide more nutritious foods or to demand that our schools contract with better food providers? Healthy breakfasts, lunches and snacks during educational hours should not be contingent on whether a child has a homemade lunch or went through the cafeteria line.

The connection for Robika

Working as a school counselor in rural Mississippi, I noticed that a disconnect existed between the medical field’s information on physical health and the knowledge of mental health within the schools. I saw many children who would likely be classified as overweight or obese, and I saw a lot of students who were unhappy about their weight. I often consulted with the school nutritionist and nurse in these instances. With these particular students, I also noticed the prevalence of several issues that extended beyond academics to socioemotional problems, including bullying, self-esteem issues and anxiety. This observation sparked my curiosity about the possible connection among these different variables.

I wrote my dissertation about the connection between childhood obesity and personal, social and academic issues. Although I didn’t find a statistically significant connection (probably because of limitations in research), I did identify individual connections in my sample between self-esteem and interpersonal relationship satisfaction. This led my wanting to know more and wanting to continue this research and advocacy within the schools.

The problem was — and continues to be — that obesity is a difficult topic for schools to address. Obesity is a buzzword that is sometimes considered offensive. It was difficult getting parents and caregivers to agree to let me weigh their children.

As Rachael and I began collaborating on this topic, questions started forming: Why are school counselors not more involved? BMI doesn’t provide a fair reading of weight for different ethnicities, so why are we using it to define weight? What other way can we measure weight to incorporate multicultural, nutritional and genetic considerations? How can we fill in this gap among the medical, school nutrition and mental health worlds? Would school counselors be comfortable talking about this topic?

These questions continue to drive us as we move into more detailed research and advocate for school counselors and for our students.

The connection for Rachael

During my doctoral research classes, a professor said to me, “Rachael, bring in any research that sparks curiosity.” This simple statement opened a wormhole of personal curiosity, followed by fear and then drastic dietary changes. Becoming a good consumer of research resulted in me experiencing emotional ups and downs, especially when I decided to read more about Food and Drug Administration food protocol, particularly around animal products.

This launched my personal pursuit of knowledge surrounding nutrition. However, the real lightbulb moment took place when a direct correlation was drawn between some of my food intake and my autoimmune disease that I had been medicating for years. It was also around this time that Robika asked me to help collect data for her dissertation. Her research lit a fire in me to implore my friends, family members and students to care more about what they were putting into their bodies. Now, as the research advances, Robika and I hope that we can support counselors in K-12 settings in getting involved in school food purchases and menu planning.

What we can do about the knowledge gap

A lack of information exists concerning how school counselors can promote wellness and nutrition in terms of social and emotional health. Researchers for HealthCorps, an advocacy group that incorporates wellness education into schools, based their study on three domains: nutrition, physical activity and mental health. However, the term mental health was a misnomer because it did not encompass all aspects of mental health. Instead, it was essentially defined as mental resilience. In addition, no counselor was included on the study’s development team, which consisted of dietitians, nutritionists, integrative human physiologists and other health care professionals.

Through our own research, we believe that we are on the path to helping school counselors promote wellness, healthy weight and mental health through prevention and intervention methods with students and their families and within the school itself. Our long-term goal is to make connections between the brain, childhood weight and mental health, and then to use this information to help school counselors collaborate with school nutritionists and communities to create better lifestyle choices and, in turn, promote socioemotional wellness. We decided that we needed to start with school counselors themselves to get a better understanding of how comfortable they are talking about these issues, and especially childhood obesity. Again, the word obesity brings up a number of issues for many people.

We have received really wonderful feedback when presenting on this topic. Not a lot of counseling research has been done in this area. As a result, we have found that many counseling professionals are very interested and agree that it needs to be researched more thoroughly. Unfortunately, presenting this line of research to the schools has been difficult. Parents tend to keep their children from participating in research related to obesity and nutrition, and school boards, faculty members and school staff often have a difficult time with it too. Realizing that school counselors may not feel comfortable using the term childhood obesity, we have since changed this term to childhood weight. In this case, we can also talk about the opposite spectrum of obesity, which includes disorders such as anorexia nervosa and bulimia.

Another aspect of what we are attempting to do is to place these terms within the context of ethnicity, age and gender. In our initial research, we measured BMI because this was the only option for calculating obesity. However, we know that some ethnicities may be more susceptible to qualifying as overweight or obese even though they are of normal or healthy weight. Another example is that athletes who are larger and more muscular are not necessarily overweight or obese, but their muscle mass may tip the scales toward them being classified as overweight.

As counselors, we have to be aware of the demographics of our communities. This is not a new concept of course, but we can start making little ripples to address a larger problem, especially in the schools. In some towns, nutritious foods are not available or affordable. High-calorie, high-fat foods are more readily available and come at lower prices. Once the cycle of eating high-calorie foods begins, it can be difficult to change it. Children who are taught about nutritious foods may mention this to their parents, but the parents may ignore the request because they cannot afford these foods or because the foods do not sound appetizing. Other parents may work multiple jobs and not have time to make meals for their families. Some families have to rely on their older children to make dinners.

Home life aside, however, schools need to work to have healthy options. Some schools will present the choice between a baked meal and a fried meal. Many students will opt for the fried meal. Although choices are important, we propose that children be presented with more healthy options. Countries around the world have lunches made from scratch that include vegetables, seafood, whole wheat breads, fruits (rather than sugary syrup) and nonprocessed meats and cheeses.

Children should also be educated about their food. This empowers them to make healthy choices based on their own knowledge. They can even be involved in planting vegetable gardens at school or preparing meals at home.

However, there seems to be no connection or collaboration between the different fields of research, even though there are several areas of knowledge that intersect.

We believe there are ways that these three knowledge bases can work together and help each other. The image on page 52 [of the print version of this article, ] shows our proposed Integrative Collaboration Childhood Weight Model, which is where our research will go next. We want to bridge the gap and highlight what the features of each area are, as well as bring them together to create a richer research model.

Our hope is to first understand school counselors’ comfort level when discussing the issue of childhood weight. We also want an idea of their understanding of the connection between childhood weight and socioemotional and academic issues. We need to know what kinds of community, caregiver and school support school counselors receive. Do they already collaborate with the other faculty and staff in the school? If so, is this on a regular basis?

Future goals include creating prevention and intervention methods and materials that will address nutrition and socioemotional wellness in conjunction with other staff in the school district. Working as a team is more likely to result in better overall outcomes. Healthier children can mean healthier adults. So, let’s be willing to talk about the connection between food and mental health.

Potential interventions, prevention methods

Given that not a lot of research has been conducted in this area, school counselors are somewhat at a loss for potential interventions for childhood obesity. Children who are overweight or obese may come to the school counselor for issues such as self-esteem, a lack of confidence or bullying (either being the target of bullying or engaging in bullying themselves). However, we cannot assume that their weight is the reason for these issues unless the child mentions it as a cause. School counselors cannot target children who are overweight or obese for individual counseling.

Although interventions can be put into place by the school counselor for the specific issues mentioned (self-esteem, confidence, bullying), we believe that prevention methods may have the most impact for all children when it comes to childhood weight. Classroom guidance lessons focused on nutrition, wellness and self-care can be part of the comprehensive school counseling program. We also want to again emphasize the potential impact of collaborating with other school staff such as school nurses, school nutritionists and physical education teachers. Providing wellness interventions for both physical wellness and mental wellness is also likely to have a greater impact on students. Teaching these methods of self-care not only helps the whole child but also gives students the tools to continue healthy living and wellness practices across the life span.

An activity that might serve a dual purpose is horticulture therapy, in which children create sustainable gardens while also working with the earth as a form of healing. Children can learn how to grow vegetables and fruits and better understand their nutritional value even as they also grow their personal and social skills. Some children may even want to grow their own gardens at home.

Parent/caregiver involvement has been shown time and time again to be related to the success of the child. School counselors and nutritionists could present workshops for parents and caregivers focused on how they can make nutritious meals for their kids and even with their kids. Information on meals and snacks that are inexpensive but also better for the family can also be shared. Teaching parents about the value of nutrition and mental health should also be emphasized. Another area of emphasis might be teaching parents and caregivers how to engage in positive body language. Parents and caregivers are models for their children, and if they speak negatively about their bodies, then their children are likely to copy that negative self-talk.

 

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

Robika Modak Mylroie is a distance clinical professor in the Department of Counseling and Special Populations at Lamar University. Her experience consists of working in the clinical setting before becoming a school counselor. Her current research includes childhood weight, trauma and animal-assisted therapy. Contact her at rmylroie@lamar.edu.

Rachael Ammons Whitaker is the program director for the clinical mental health and school counseling programs at the University of Houston. She worked as a behavioral therapist, behavioral interventionist supervisor and school counselor before pursuing counselor education at the university level. Her current research includes understanding and advocating for intersex children and the impact of childhood weight. Contact her at rachaelammons@yahoo.com.

Letters to the editor: ct@counseling.org

 

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

The Counseling Connoisseur: New Year’s resolutions

By Cheryl Fisher January 12, 2018

“When the well is dry, we know the worth of the water.” — Benjamin Franklin

 

The holidays are over. The ornaments are boxed and put away. The tree is at the curb ready to be recycled for mulch. The eggnog and cookies are gone leaving behind only the memory as I tug my snug jeans over my more rounded hips. I sit back in my recliner and sip my holiday tea which offers hints of mocha and peppermint, evaluating this past year’s events.

It was a year filled with grief and transition: The death of a beloved pet, job transitions and surgeries. It was also a year of beginnings and opportunities: New speaking engagements, a book contract and a new academic position. In 2017, life continuously oscillated between joyous highs to devastating lows. What a ride!

I evaluated my self-care over this past year and (like many) I find I fell short in some areas. I exercise regularly and eat well, but I still don’t drink enough water. I overschedule, loving everything I have the privilege to do — but leaving little space for much needed quiet. I want to write more and that requires (at least for me) quiet and time. So, I put pen to paper and begin my process of resolving to offer myself better care in the New Year … and so it begins.

 

Wellness Wheel

The idea of self-care, although essential, tends to elude caregivers and those of us in the helping professions. We preach it to our clients. However, we become our own exception to the rules of wellness. Further, overall wellness encompasses all aspects of our life to include relationships and finances. The United States Substance Abuse and Mental Health Services Administration (SAMHSA) has created a wellness model that includes eight dimensions that contribute to physical and mental health.

  1. Emotional

Helpers need help, at times, in processing difficult experiences. Recently, a grieving therapist-friend lamented: “We are all liars! We tell our clients all about grief and loss, assuring them that things get better … but they don’t!”

I allowed her to continue her disgruntled evaluation of the pain and suffering that accompanies grief and then asked, “So, you are saying that just because we as clinicians know the grief process we are not immune to the actual pain?”

We bleed just like any other human, I reminded her. We feel hurt, and pain — and we suffer. Even if we have an intellectual understanding of the process, we still must endure the journey.

What supports do you have in place? Who can you call upon for guidance? How are you coping with your life’s challenges?

  1. Environmental

Our internal wellness is informed by our external surroundings. When I decided to start a private practice, I created a vision around the environment in which I wanted to spend six to eight hours each day seeing clients. I thought of my favorite colors, turquoise and green, and the most peaceful setting: the beach. I went to my nearest Pier 1 Imports store and let the designer go to town picking out dark-stained wicker furniture with pillows and wall art of batik with inspirational hand-painted words such as love, inspire, believe, peace. I added a few pieces of sea glass and shells from my travels and voila!

How do your personal and professional environments support you? Do they offer a peaceful haven or chaos and disorganization?

  1. Financial

Financial wellness is an area that many individuals find difficult to examine. Early in my career I was barely making enough to pay my bills, let alone think about a portfolio. However, what I have learned is that seeking the expertise of a financial professional helped me begin to see how I could create a solid personal plan — even with meager beginnings. There are numerous resources that can help address your financial needs and help you develop a realistic plan. It is easier than you think!

How are you contributing to your financial health?

  1. Intellectual

We are creative beings. We need stimulation and imaginative ways to express and expand our knowledge and skills. For example, a year before ACA’s 2016 Conference & Expo in Montréal, I committed to learning a bit of French. I spent every morning rehearsing. My mother, who is French- Canadian, tested me as we ventured through the produce isle of a grocery store.  More recently, I became a student of backyard foraging. Yes, I walk the trails looking for bounty: wild berries, mushrooms, rose hips and greens. My passion for nature therapy ignites as I learn more about the intricate communication between the plants and animals. I get excited when I put together a delicious feast from my foraged treasure.

In what ways are you stimulating your mind?

  1. Occupational

I love my work! Each day I experience variety in client needs. I enjoy sharing theory and application with my students. Writing joins my clinical and academic work to complete my professional trifecta. I love my work so much that I often overschedule: I see 30 clients in my practice, I teach six classes for three universities, I am a national presenter, I have a column that I contribute to monthly, and now I have a book contract and a full-time university faculty offer. Clearly, something has to give (stay tuned!).

How does your occupation meet your needs? Are you satisfied with your work-life-balance? Or, like me, is it time for you to re-evaluate?

  1. Physical

Our bodies need attention. We need food, water, rest — and to be active. Exercise is such an important part of my life. I like to move. It feels good to sweat. Yet, I have an incredibly sedentary job — I sit all day long. In addition to my hour-long gym class, I’ve created movement throughout my day to mediate the effects of hours of sitting. Others with sedentary jobs are employing standing desks, or taking short walks around the office just to stretch. My Fitbit reminds me to attend to all of the elements of physical health.

How are you taking care of your physical wellness? Do you carry a water bottle to hydrate? Do you take walks regularly and get fresh air?

  1. Social

We are social creatures. Abraham Maslow pointed out decades ago that once the immediate needs of food, shelter and safety have been met, we need to feel like we belong. That sense of belonging comes from having the support of others. For some, family may not serve as a support system. While my family is a source of great support, I also like to create a network within my community. For example, when I moved to Annapolis (almost 20 years ago), I did drive-by visits to my most important sources of connection. I interviewed churches. I located gyms. I identified several coffee shops. I found dog parks and trails.  Clients have since told me about the Meetup.com concept of identifying groups of like-minded persons.

How is your social wellness?

  1. Spiritual

In The Gifts of Imperfection: Let Go of Who You Think You’re Supposed to Be and Embrace Who You Are, author and researcher Brené Brown writes:

“Spirituality is recognizing and celebrating that we are all inextricably connected to each other by a power greater than us, and that our connection to that power and to one another is grounded in love and compassion.”

Research continues to find that experiencing the sacred provides us with wellness, healing, support and a sense of meaning.  Years ago, I helped my faith community start a Prayer Shawl Ministry (a spiritual practice that involves shawls that provide comfort and solace to those in need). As a card-carrying feminist, I am drawn toward the feminine sacred, even within traditional religious practices. So, it was such a great opportunity to convene with other women in meditation and click our needles together with intention as we crafted shawls for ill church members. Influenced by my Celtic heritage, I find beauty and the divine in natural settings. Engaging in nature is sacred for me and promotes moments of awe and wonder. It nourishes my spirit.

 

How do you cultivate awe and wonder in your life? What do you find sacred and meaningful? How do you craft opportunities to nourish your spiritual health?

  

Conclusion

It is a new year. A time to ponder past experiences and future dreams, re-evaluate relationships and let go of old habits and develop newer, more nourishing, ones. As I review my wellness wheel, I find that there are several areas with which I am pleased — and a few that I will choose to modify in order to bring greater balance to my rich, full life.

 

Be kind to your body, gentle with your mind and patient with your heart.

Stay true to your spirit, cherish your soul and never doubt yourself.

You are still becoming, my love, and there is no one more deserving

of the nurturing grace of your love.

“Kindness” -Becca Lee

 

Happy New Year!

 

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Cheryl Fisher

Cheryl Fisher is a licensed clinical professional counselor in private practice in Annapolis, Maryland. She is affiliate faculty at Loyola and Fordham Universities. Her research interests include examining sexuality and spirituality in young women with advanced breast cancer; nature-informed therapy; and geek therapy. She may be contacted at cyfisherphd@gmail.com.

 

 

 

 

 

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