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Wellness

Digesting the connection between food and mood

By Lindsey Phillips December 31, 2019

For most of her life, the woman would not let herself eat cake. She feared that if she started, she would never be able to stop. The presence of cake at every birthday party she attended tormented her. She grew so preoccupied with thoughts of cake that she had food fantasies about eating it.

The woman’s unhealthy relationship with food eventually led her to Michele Smith, a licensed professional counselor who operates a private practice called The Runaway Fork in Westfield, New Jersey. With Smith’s guidance, the woman decided to conquer her fear by eating a sheet cake while she was alone.

The client took her first bite, but it wasn’t the experience she had fantasized about. It tasted artificial and waxy. She thought perhaps it was only the frosting that she didn’t like, so she took another bite, this time focusing more on the cake itself. It only confirmed the horrible taste from her first impression. The woman ended up throwing out the entire cake.

The client’s craving for cake had caused her years of suffering, yet when she finally ate it mindfully, she discovered that she didn’t even like it, says Smith, who is also a licensed mental health counselor in New York.

“There’s all this unnecessary suffering around food, weight and body,” Smith continues. At the same time, “there seems to be a lack of services available for everyday people who do not have eating disorders [but] who want to discuss and heal their relationship with food, body and weight.”

For this reason, Smith, a certified mind-body eating coach and a member of the American Counseling Association, created her private practice to help people who struggle in their relationship with food. She doesn’t have a precise phrase to explain this special niche she has carved out with her counseling practice, but she says it differs from nutritional counseling, which focuses on helping clients figure out what to eat. Instead, Smith attends to who clients are as “eaters.” This includes connecting their relationship with food to other life domains and psychosocial factors — such as anxiety, depression and trauma — that professional clinical counselors work with every day.

Researchers are not completely sure how food fits into the overall mental health equation, but recent studies suggest a strong connection. In general, food can promote wellness in three ways: 1) by providing the brain with nutrients it needs to grow and generate new connections, 2) by tamping down inflammation and 3) by promoting gut health.

In 2017, the world’s first study of dietary intervention for clinical depression, called the SMILES trial, found that a modified Mediterranean-style diet (which encourages whole grains, fruits, vegetables, legumes, low-fat/unsweetened dairy, raw unsalted nuts, lean red meat, chicken, fish, eggs and olive oil, while discouraging sweets, refined cereals, fried foods, fast foods and processed meat) resulted in a significant reduction in depression symptoms when compared with the typical modern diet loaded with fast food, processed foods and refined carbohydrates.

A randomized controlled trial published last year in PLOS ONE supports the findings of the SMILES trial. Researchers found that adults who followed a Mediterranean-style pattern of eating for three weeks reported lower levels of anxiety and stress and a significant decrease in their depression symptoms.

These and other findings suggest that counselors should no longer think of mental health in isolation but rather as part of a complex system that includes what people eat.

A missing piece of the mental health puzzle

Lisa Schmidt, a licensed associate counselor, certified whole foods dietitian nutritionist, and instructor in the School of Social Work at Arizona State University, points out that people seldom think about what they eat. “The act of eating is considered a nuisance. It’s something people don’t have time for until they’re just so hungry, they have to eat something, and when you get to that point, you often make very poor nutritional choices,” she says.

For instance, people may grab fast food and eat it in the car on the way to their next meeting or to pick up their kids. Then, when they have trouble sleeping later that evening, they assume it is related to their feelings of anxiety, thus overlooking any possible connection to food, Schmidt adds. 

“Most people don’t know that the kind of foods we choose [to eat] can help us regulate our nervous system and perhaps is the missing link in mental health care,” Schmidt notes.

Schmidt, an ACA member in private practice in Scottsdale, Arizona, says that mood-related disorders often have a food component to them because nutrition-poor diets affect mood. The standard American diet, often aptly referred to by its acronym SAD, frequently leads to people being hungry and tired and having dysregulated moods, she continues. People often alternate between periods of escalation, during which they fuel themselves with caffeine, processed sugar and refined carbs, and periods of starvation. This unhealthy pattern leads to dysregulated moods, Schmidt explains.

In addition, stress (which is common in fast-paced, disrupted lifestyles) dysregulates people’s nervous system responses. When people are stressed and in fight-or-flight mode, their bodies secrete glucose into the bloodstream, fueling them to run away from real or imagined danger. Then the pancreas secretes insulin as it tries to regulate blood sugar levels, Schmidt explains. These swings in blood sugar levels affect mood and can lead people to become “hangry” — hungry and angry, she adds.

Two researchers at the University of North Carolina at Chapel Hill recently set out to study the underlying mechanism behind the complicated “hangry” reaction, and their results challenge the theory that hanger is the result only of low blood sugar. They found that hunger-induced feelings can lead to tantrums and anger when people are in stressful situations and are unaware of their bodily state. In other words, hunger pangs might turn into other negative emotions in certain contexts.

This suggests that people should slow down and pay attention to both their physical and their emotional cues. Smith advises her clients to carefully set the scene before eating, telling them that eating should be stress free, relaxing and pleasant. To achieve this, they might consider using a candle or playing calming music. They shouldn’t be using their phones, watching television or walking around, she says. And although some families use dinner as a time to reprimand their children, there shouldn’t be any arguing while eating, Smith adds.

Because the quickest way to relax the body and mind is through breathing, Smith instructs clients to take as many deep breaths as they need to calm down before they begin eating. She also recommends that clients put their forks down between bites or use their nondominant hand to help them slow down and fully experience their food.

Mindful eating also involves approaching the meal with all of the senses, Smith says. She often illustrates this type of eating in session by having clients — especially those prone to eating quickly or eating distractedly as they work or stare at a screen — engage their senses while eating a Girl Scout Thin Mint cookie. During this activity, Smith asks clients to forget about their ingrained diet rules, negative self-talk, or whatever else might be in their heads and focus on their bodily experience of eating.

First, she has clients look at the cookie so the brain will register that food is present. Next, she has them touch the cookie and notice its texture. Then Smith asks them to smell the Thin Mint because scent affects our pleasure or displeasure with food. Once clients put the cookie in their mouths, they slowly roll it on all parts of their tongues without biting into it. When they finally bite the cookie, they listen to the sound it makes and notice how it tastes and when the taste starts to diminish. At the end of the exercise, Smith asks clients to rate their experience as pleasant, unpleasant or neutral. 

This simple exercise is an eye-opening experiment for most of Smith’s clients, who often admit they would normally just throw the cookie in their mouths and not think twice about it. When people learn to slow down and eat mindfully, they become better at noticing when they are full or if they are no longer tasting their food. Smith says one of her clients discovered through the exercise that she actually didn’t like Thin Mint cookies, even though she had eaten them all of her life.

It’s one thing to tell clients what mindful eating is; it’s another thing for them to experience and feel it for themselves, Smith says. “Mindful eating as a practice can be helpful at reawakening [our] appreciation for food,” notes Schmidt, author of Sustainable Living & Mindful Eating. “As we wake up to how we feel and what we experience, we have the possibility of change.”

The emotional toll of restrictive eating

“Every diet is some form of food restriction,” Smith asserts. “When you eliminate certain foods or when you deem certain foods bad or forbidden, you’re actually going to create the overeating through that sense of deprivation.” For example, the night before someone starts a no-carb diet, he or she might binge on bread as a “farewell” (often referred to as “Last Supper” eating). People on diets never reach habituation, so when they are exposed to restricted foods, they may overeat them, which only reinforces the idea that they can’t be trusted around a particular food, Smith adds.

Licensed clinical professional counselor Heather Shannon wrote a book chapter on nutritional stress management strategies for volume one of the book Stress in the Modern World: Understanding Science and Society. She says the all-or-nothing, judgmental thinking that is common with most diets often creeps over into character judgment: “I’m bad because I ate that carb” or “I feel horrible that I cheated on my diet by eating that cupcake,” for example.

Shannon, who offers coaching and teletherapy as a psychotherapist at Lotus Center in Chicago, had one client who was fit and healthy but fixated on losing three pounds. One morning, the client woke up feeling great, but the second she stepped on her scale and saw she had gained one pound, her mood changed. She went from feeling wonderful to feeling horrible in two seconds.

Fixating on an outcome, such as the number on the scale or the number of times a person has gone to the gym that week, is a big part of anxiety, Shannon says, and it opens up the possibility of good and bad labeling (e.g., “I’m bad because I went to the gym only once this week”). Instead, she helps clients focus more on their habits and which habits make them feel good, healthy and connected to their bodies. “If you’re treating your body really well, then whatever the results are is how your body is supposed to be,” she says.

Smith, a certified intuitive eating counselor, helps clients let go of the dieting mentality and reawaken their intuitive eater. In the intuitive eating model, there are no “good” and “bad” foods. Smith describes it as “a non-diet, flexible style of eating where you follow your internal sensations of hunger and satiety to gauge what, when and how much you eat.”

Smith points out that not every client will automatically be ready to put all foods back on the table. Under those circumstances, counselors can instead help raise awareness around dieting and how it may be interfering in clients’ lives. For instance, counselors might ask: How has your diet affected or changed your relationships with others? How much time and money have you spent on diets? How has it affected your social life and mental health? What in your life has changed because of dieting?

Schmidt also tries to help clients adjust their mindset around food. “Nourishment is not determined by one episode,” she says. “It’s an eating pattern over time.” For this reason, she advises clients to follow the 80-20 rule, in which 80% of the time people make choices that are whole foods (mostly plant-based), and then they don’t need to worry about the 20% of the time that they have a treat or indulge.

“We eat for reasons that are other than just to feed our bodies,” Schmidt says. “We eat as part of celebrations, and food is pleasurable. So, adopting a very restrictive, Spartan way of eating” — particularly one that demonizes any particular food group — “… can become disordered eating and cause problems for some people. … And research shows eating this way will fail 95% of the time.”

Instead of adopting the latest diet fad, people should find a way to eat that they can follow for the rest of their lives and that simultaneously supports their health and mood, Schmidt says.

Using foods to cope with moods 

If clients understand biological hunger and still reach for food without feeling hungry, then they are often engaging in emotional eating, Smith says. This may mean that a client eats because of unresolved trauma or grief. Maybe the client has perfectionist tendencies and uses food to manage his or her anxiety. Or perhaps food is the way a client copes with being in a marriage or job that makes them unhappy.

Smith works with clients to figure out what they are feeling — such as anxious or lonely, for example — when they experience emotional hunger. “This is where the mental health piece comes in,” she says. “You’re talking about eating, but the root cause of the eating is really psychological issues. … They’re people pleasing. They need boundaries. They need to be assertive. They need to say no to people and they can’t, so they use food to cope.”

Shannon, author of the ACA blog posts “Nutrition for Mental Health” and “How Does What You Eat Affect How You Feel?” finds the internal family systems approach effective for uncovering underlying issues associated with emotional eating, especially if clients have a playful side. She first helps clients identify the part of themselves that is overeating by asking what this eating part of them feels like in their bodies. One client might feel it in their stomach, whereas another client might sense it as a coach whispering in their ear.

Shannon also instructs clients to personify the part of them that is overeating by naming it (for example, the Snacking Part, Cake, or even a human name such as Maria). Then, both she and the client can easily address and reference this personified part.

Shannon might ask the part, “What is going on when you overeat?”

And the part almost always provides an answer. For example, “Well, I feel like I work too hard, and I need this because it’s my pressure release valve” or “I feel like I can’t count on people, so I’m counting on food.”

Smith and Shannon both caution against having clients keep a food journal that tracks food intake or weight. They say that activity takes clients out of themselves rather than tuning inward. In addition, they warn, it can promote obsessiveness. But they agree that clients can benefit from journaling about their emotions and feelings associated with food. For example, a client could write down what he or she feels right after overeating as a way of identifying what emotions are associated with the behavior. 

Schmidt has clients keep a food and mood journal, but not to track food intake or to promote weight loss. Instead, the goal is to help clients build an awareness of when they’re eating and how they feel before and after eating. This ultimately gives them a better understanding of how food affects their mood and how mood can affect their eating habits.

She provides an extreme but not unusual example: While journaling, a client noticed that they did not eat anything until 2 p.m. They felt terrible but only had 10 minutes to eat, so they ingested a protein bar and soda. Immediately afterward, they felt good, but an hour later, the client was starving, mad and stressed again.

“Most people … spend less than two minutes a day thinking about what they’re going to eat. They just react,” Schmidt says. “So, building awareness of all our habits, including our fueling habits, is really important.” 

In addition, if people are not fueling their bodies in a healthful way, it will create difficulties for them, Schmidt says. Chronic pain, substance abuse, anxiety and depression are all issues for which food is a huge component, she asserts. Schmidt had a client who would eat seven to nine bowls of Froot Loops for breakfast while in recovery from drug use. People recovering from substance use may often transfer their addiction to food, especially highly processed, sugary types of foods, she says.

Smith encourages her clients to approach their relationship to food with a compassionate curiosity. Clients can view nutritional changes as an experiment to figure out how their bodies react or what works best for them, she explains. Also, if clients haven’t fully mastered their new coping skills and continue to engage in emotional eating, then Smith advises them to be compassionate with themselves and say, “I’m reaching for food, and I know I’m not hungry. I look forward to the day when I can cope with my emotions without using food.”

Staying within scope

Smith has noticed that many counselors shy away from discussing any issue related to food with clients, reasoning that it falls outside their scope of practice and because becoming a certified eating disorder specialist or nutritionist requires specialized training. But she encourages counselors to rethink this mindset. “It’s not out of [counselors’] scope of practice to talk about people’s relationship with food. It’s such a critical part of everybody’s day. So, to not look at it is missing a big part,” Smith says.

“You don’t have to talk about the grams of protein per se, which is out of our scope … to really help somebody,” she continues. “Because [clients are] dying to talk about it, and they need that space. And it’s connected to so many other life domains [e.g., trauma, grief, anxiety, depression, stress] which counselors are more than equipped to talk about.” 

As a certified health coach, Shannon says she would never prescribe foods for clients or tell them what they should or shouldn’t eat, but that doesn’t prevent her from talking about food in session. In fact, on her intake form, she screens for potential issues with food by including general questions such as: What do you generally eat for breakfast, lunch and dinner? Do you snack or skip meals? Do you overeat or under eat? Then, in her first session with clients, she discusses this information and asks follow-up questions to gain a better understanding of clients’ relationship with food and the way this could be affecting their mental health.

“Even if you’re not a nutrition expert, we all know some basic stuff. We all know whole foods are better than processed foods. We all know excess sugar is not helpful,” Shannon says. For this reason, she recommends that counselors screen for basic nutritional information to see if food might be a piece of the client’s mental health puzzle. 

Rather than telling clients what to eat, Shannon takes a behavioral approach and asks, “What are you eating, and how is that working for you? What do you think might work better?” Sometimes, she will also provide clients with helpful resources and advise them to talk to their doctor or a nutritionist about other options they could pursue.

Schmidt finds that discussing alcohol use with clients can serve as a great segue into talking about their diet in general. In her experience, alcohol often comes up with clients who have mood disorders, and because alcohol is a nervous system depressant, it is not advised for these clients. While discussing their alcohol use, Schmidt will ask other questions about their diet, such as if they eat breakfast consistently or if they eat lots of processed, high-sugar foods. From there, she might suggest that clients try to limit the amount of food with added sugars that they eat and experiment with eating fresh fruit as a snack or dessert most days of the week. Schmidt will also use the Healthy Eating Plate (created by Harvard Health Publications and nutrition experts at the Harvard School of Public Health) as a way to help clients visualize how to build meals that support balanced moods.

Schmidt recommends that counselors interested in the food-mood connection experiment with their own eating habits to see how this affects their mood. “It is particularly difficult for a counselor who has a poor diet to talk about the food-mood connection with a client,” she says. Similar to how counselors practice meditation themselves before teaching it to clients, Schmidt believes counselors should first reorganize their own way of eating to include mostly foods derived from plants, to limit caffeine, and to limit or eliminate alcohol.

After counselors have experimented on their own with the food-mood connection, Schmidt says, then they can ask clients to do a chain analysis. For example, if a client is having panic attacks, the counselor might ask, “What do you remember doing just before the panic attack? Did you have anything to eat or drink? If so, what did you eat or drink?” Maybe the client will say that he or she remembers drinking coffee or alcohol before the panic attack happened. The counselor could follow up and ask whether the client noticed any change in how he or she felt after drinking three cups of coffee or drinking alcohol to excess before having a panic attack. This technique will help clients connect their dietary choices, which are ultimately under their control, to the way their mood is affected, Schmidt says.

Smith acknowledges that counselors’ scope of practice does limit just how far they can go in addressing food issues with clients. For instance, counselors cannot provide nutritional advice to clients. “That creates this barrier that is hard to get around,” she says. “So, then, you do have to reach out to other professionals like nutritionists and dietitians and really work as a team.” She says counselors can either work with a nutritionist to determine what nutritional treatments and approaches are best for the client, or work with clients to ensure they are advocating for their own dietary preferences (such as using plans that focus on well-being instead of weight loss) with the nutritionist or speaking up when they feel a certain nutritional approach is harming or not helping them.

But at what point should counselors refer to a nutritionist? Counselors have referred clients to Schmidt, in her role as a nutritionist, because they suspected their clients had an eating disorder or were binging on foods. Schmidt thinks it is a good idea to also refer to an eating specialist if clients talk about food or their bodies frequently in counseling, are extremely overweight or underweight and the condition is disruptive for them, or have suddenly lost a significant amount of weight.

When finding referral sources, Schmidt recommends that counselors look for professionals trained in the Health at Every Size approach, which promotes size acceptance and serves as an alternative to the weight-centered approach.

Smith agrees that “the focus always has to be on wellness, not weight loss.” She advises counselors against referring clients to dietitians, nutritionists or doctors who track calories, encourage weigh-ins, or engage in fat shaming. Instead, she suggests looking for health professionals who teach intuitive eating and operate from a weight-neutral model.

Adding in the nutritional piece

People routinely look for mental shortcuts or a magic bullet to solve their problems, and this tendency extends to food consumption. From research, we know that people will tend to eat 30% more of a food that they deem “healthy,” Schmidt notes. Researchers even have a name for this tendency to overestimate the overall healthfulness of an item based on a single claim such as being low calorie or low in fat: the health halo effect. This halo effect appears to encourage people to eat more than they otherwise would because they feel less guilty about consuming the food.

Clients often come to see Smith because they are confused and don’t know what to do. They have dieted for years with little or no success, and they are confounded by all the conflicting nutritional advice. For Smith, it comes down to a core question: “How does this [food] feel in your body?”

“You’re making peace with food,” she says. “This is your journey of one, and only you can know whether pizza feels good or depleting and when and under what circumstances.” Counseling can help clients tune in to their own unique nutritional needs and preferences and connect this piece to how their mood is affected, Smith says.

Schmidt advises counselors to focus on the big picture and not get caught up in one particular approach to eating. Instead, it is about helping clients make their own connections between what they are eating and how it affects their moods.

Also, because everyone is unique, the nutritional advice that has benefited a counselor personally may not help the counselor’s clients. However, the majority of clients (and all people) need to eat more fruits and vegetables, so if counselors encourage them to do that, it could have a huge impact on clients’ health and mood, Schmidt asserts.

“Having a personal connection to food and its life-giving properties is one of the most amazing gifts we can give ourselves, as well as elevating the status of food and eating for our clients,” Schmidt says. “Helping clients understand that the process of food and feeding is a central part of their recovery is a message that’s independent of what they should be eating.”

“Nutrition is always a piece of the puzzle,” Shannon adds. “So, by understanding the nutrition …
even a little bit, you’re going to be potentially twice as effective working with your clients.”

 

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

Letters to the editor: ct@counseling.org

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

Interventions for attachment and traumatic stress issues in young children

By Cirecie A. West-Olatunji, Jeff D. Wolfgang and Kimberly N. Frazier April 2, 2019

Although mental health professionals acknowledge that clinical issues often look different in young children, treatment practices continue to rely heavily on adult literature. These mostly miniaturized forms of adult treatment are often scaled down using more basic language and vocabulary, but they still depend on discovering ways to encourage the verbal communication of children. Furthermore, major deficiencies exist in the mental health care delivery system for children. General neglect and fragmentation of services create obstacles to effective service provision for this population.

Over the past decade, scholars have begun exploring early childhood development and effective counseling interventions, the role of traumatic stress in the presentation of emotional and behavioral symptoms, and the prevalence of attachment issues for young children. In this article, we aim to provide a brief overview of these key advances in what we have named “pediatric counseling.” We also offer 10 evidence-based counseling interventions that stem from our work with young children over several decades.

Early childhood development and counseling

Children are not miniature adults, meaning a paradigm shift and specialized skills approach are required to help them most effectively. Children also go through rapid developmental stages, strengthening the argument that therapy with children should be vastly different from therapy with adults. Thus, professional counselors and other mental health professionals must consider various concepts, issues, techniques and interventions that are cognitively, emotionally, psychologically and developmentally appropriate for children.

During early childhood, defined as birth to age 5, rapid development of gross motor skills (running, climbing, throwing) occurs. Fine motor skills (drawing, writing, manipulating small objects) are slower to develop at this stage, but children should be able to copy letters and small words sometime during the latter half of early childhood. Cognitive development at this stage is based primarily on preoperational thinking. Hence, children in this stage rely heavily on what they see. They can now recall past events and anticipate future experiences that may be similar. At this stage of development, children are very egocentric, commonly overestimate their abilities (e.g., thinking they can carry things that are too heavy for them), and gain increased control of their impulses.

Play is extremely important to social development during early childhood. At about 3 or 4 years old, children engage in associative play in which they learn how to share and interact with one another. During associative play, there are no clear goals for the play and the roles of those engaging in play are not assigned. At about age 5, children begin to create games, form groups and take turns. Children are expanding their vocabularies at this stage, but the words and phrases used to express feelings and emotions remain limited. Because of their limited emotional vocabulary at this stage, children are more prone to act out their emotions behaviorally.

Deficiencies in service delivery:
Some of the major deficiencies in the mental health care delivery system for children include:

  • How children are categorized (i.e., poor conceptualization of children within their ecological context, including culturally marginalized children being overrepresented in the most severe clinical categories)
  • Environmental factors (such as racism and poverty)
  • Lack of empirical data
  • Fragmentation of services

First, children are typically placed in categories of clinical, subclinical and at risk, and they are often in need of services such as remediation and prevention. However, they are largely neglected within the system. This is partly due to clinicians’ lack of training to provide developmentally appropriate clinical care for this age group. Lack of adequate funding and poor communication between providers (such as pediatricians, child care workers, parents/caregivers, social services personnel and professional counselors) are also factors.

Second, some environmental factors associated with higher rates of mental health problems include poverty, racism, abuse and familial problems. Systemic oppression is also linked to both behavioral and affective problems. However, insufficient research has been conducted with young children to provide adequate information about how these environmental factors affect them. 

Third, there is a lack of empirical data on effective treatment for young children. Although the literature is replete with community agency programs and hospital-affiliated programs designed for young children and their families, there is insufficient support for the effectiveness of the treatments and interventions provided.

Finally, there is fragmentation of the services that exist for this population. Mental health services for young children should be initialized by a social service agency or primary care physician. However, this rarely happens. Even when it does, it is unlikely that these professionals have included or interacted with counselors. Thus, many children slip through the cracks and remain unidentified until a crisis arises, meaning they are most likely to receive psychological first aid via psychiatric services.

Counselor training: Experts stress the need for counselor trainees to acquire foundational skills that serve as underpinnings for effective counseling of this population. The major challenge within the discipline of counseling is how to transform these base-level skills into effective techniques and interventions for young clients. Many beginning counselors feel ill-prepared and are often frustrated when they encounter child clients — and preschool-age children in particular. Most counselors begin their training by practicing their counseling skills on classmates and never encounter younger client populations until they are out in
the field. 

Traumatic stress issues

Researchers have suggested that symptoms of traumatic stress in early childhood include interrupted attachment displays of distress such as inconsolable crying, disorientation, diminished interest, aggression, withdrawing from peers, and thoughts or feelings that disrupt normal activities. Traumatic stress, a condition caused by pervasive, systemic external forces, can result in physiological, psychological and behavioral symptoms that negatively affect everyday functioning.

Symptoms of traumatic stress can include hyperarousal or hypoarousal, avoidance and re-experiencing. Hyperarousal in early childhood is often observed through displays of inconsolable crying, flailing about, arching the back and biting. Hypoarousal involves emotional numbing that may be observed as a child who sleeps excessively, displays a dazed expression or averts his or her eyes. Avoidance is characterized by withdrawal, which is often demonstrated as displaying less affection, consistently looking away or avoiding facial contact. Other observable features of avoidance include a fear of being separated from caregivers, refusal to follow directions, disorientation and extreme sadness.

Re-experiencing is often the most subtle of the three symptoms, but it can be observed through the presence of rigid and repetitive patterns. These patterns can include common play leading to outbursts or withdrawal if the pattern is changed or interrupted. The play or reenactments have a noticeable anxious quality to them, or the child appears to space out when engaged in these patterns. One of the most consistent observations of re-experiencing is the presence of nightmares.

Neurological responses to traumatic stress include:

  • Increased levels of adrenaline (activation of the sympathetic nervous system)
  • Decreased levels of cortisol and serotonin (a reduced ability to moderate the sympathetic nervous system or emotional reactivity)
  • Increased levels of endogenous opioids (which result in pain reduction, emotional blunting and memory impairment)

In addition, chronic stress can interrupt cognitive functions such as planning, working memory and mental flexibility. Hence, it is important to systematically assess how children use relationships, interact with others and interact with their environment. Furthermore, when traumatic stressors deplete the coping resources of caregivers, they can become neglectful or show signs of chronic danger, leading to the potential disruption of the attachment system for young children.

Attachment issues

Attachment research describes children’s behaviors along a wellness spectrum from secure attachment (most well) to insecure attachment (where children are at highest risk). With secure attachments, caregivers display relaxed, warm and positive interactions involving some form of direct expression of feelings or desires and the ability to negotiate conflict or disagreement. In this manner, caregivers are encouraging, sensitive, consistent and responsive. With insecure attachments, the child loses confidence to varying degrees in the caregiving system, believing that the caregiver lacks responsiveness and availability during times of distress or trauma.

Securely attached children typically display the following healthy behaviors during the different phases of growth:

  • Phase I (0 to 3 months): Newborns often seek out connection (eye contact and touch) and respond to familiar smells, sights and sounds.
  • Phase II (3 to 6 months): Infants begin to orient to familiar people (preferring those who are familiar to them while avoiding those who are not familiar) and are emotionally expressive, responding to others’ emotional signals.
  • Phase III (6 months on): Infants become wary of strangers and actively seek out familiar caregivers. Additionally, they begin practicing verbal and nonverbal displays of happiness, sadness, anger and fear.
  • Phase IV (from the second to third year on): These young children notably gain increased abilities to negotiate with caregivers (sometimes resulting in short-lived tantrums), are better able to coordinate goals with others (showing adaptable and responsive goals), display increasingly empathic responses to others, and progressively develop greater walking and complex verbal communication skills.

Insecure attachments styles are divided into three categories: avoidant, resistant and disorganized-disoriented. Avoidant attachment styles often can be associated with caregivers who minimize the perceptions of young children, are emotionally unavailable, and assign care of the child to others. This results in young children becoming indifferent to the presence of the caregiver, displaying detached/neutral responses to others, and minimizing opportunities for interaction with others.

Resistant attachment styles are associated with caregivers who resist distress (showing avoidance verbally or physically) and often wait for the child to get highly upset before attempting to sooth. This conditions young children to maximize distress, to resist or display difficultly in being soothed, and to under-regulate their emotions (e.g., responding dramatically to change and acting out dramatically when expectations are not met). Additionally, these children readily perceive experiences as threatening, get frustrated easily, and often approach life anxiously or as if helpless. These children initiate their interactions with others through their distress.

The third and most unhealthy attachment style is disorganized-disoriented. It is associated with caregivers who are often confrontational, helpless, frightened or disengaged (avoidant). These caregivers often passively place children at risk due to the caregivers’ lack of involvement or preventive parenting skills. Their children respond by attempting to adapt to the caregivers’ emotional needs — either caretaking or avoiding. These adaptive behaviors are often observed as consistent displays of confusion, hostility, freezing responses or caregiving responses (e.g., reassuring, pleasing, cheering up).

Counselors’ role: As counselors, we are uniquely trained to meet the needs of young children because of our emphasis on human development, prevention, ecosystems and wellness. Counselors can use three main restorative skills to intervene with young children experiencing attachment issues related to traumatic stress. We can:

  • Set up a safe and warm environment in our clinical settings
  • Display trust through culturally sensitive gestures, tone of voice and facial expressions
  • Nurture a nonjudgmental understanding of young clients while focusing on exploration, empowerment and acceptance

By engaging in these three practices, professional counselors should be able to aid young children in working through a variety of social, emotional, behavioral and learning challenges. Counselors can foster warmth and vitality by employing mutuality and relational socio-dramatic play experiences. Additionally, counselors can create mediated learning so that young children can develop the ability to self-define, contextualize and transform their reality into healthy developmental journeys. This gentle, nonthreatening rebalancing of the energy can create restorative opportunities.

Ten evidence-based interventions

In 2000, Cirecie A. West-Olatunji (one of the co-authors of this article) and a colleague created a program called the Children’s Crisis Unit, in partnership with a local YWCA rape crisis unit, to provide clinical services to young children in a five-county area when referred for allegations of child sexual abuse. Over a four-year period, the Children’s Crisis Unit provided assessment and intervention for children and provided consultation to clinicians, law enforcement, medical professionals and legal professionals, both locally and nationally. During this time, training was provided for counseling, psychology and social work graduate students who learned how to work specifically with clients from birth to age 5.

The following techniques were used systematically with hundreds of clients. Although these interventions may be similar to those used with nonsymptomatic children, in working with young children, there are several unique features, including:

  • Assessment for degree of severity
  • Remediation
  • Involvement of the caregiver
  • Bookmarking for interventions at later developmental periods

1) Popsicle sticks: This intervention can be introduced in the first session with the primary caregiver and the child. One of the appealing things about the use of Popsicle sticks is that they are very inexpensive, meaning nearly any family can afford them. Counselors can use nontoxic crayons or markers and other craft tools such as glitter, buttons, yarn and nontoxic glue. Counselors direct the caregiver-child dyad to use the Popsicle sticks to create individual members of their family as dolls. This activity can be continued at home between sessions. This intervention facilitates bonding and trust, decreases anxiety, is client-centered and culturally appropriate, and allows children to tell their story.

2) Feeling faces: This activity provides easy access for the counselor because various versions can be downloaded from the internet. Use of the feeling faces allows children to identify with other children and their facial expressions. In the exercise, the counselor directs the child to select those faces to which he or she is drawn to determine thematic links between the selected faces. The counselor then hypothesizes and contextualizes the presenting problem. This activity is useful in remediating flattened affect, with the counselor directing the child to mimic faces that match a range of emotions.

3) Storytelling: Narrative activities allow children to tell stories of their own choosing or give a particular recounting as directed by the counselor. Storytelling also allows the caregiver to recount or read the child a story that represents some resolution to the problem. Additionally, this activity permits the counselor to a) read the child a story representing some resolution to the problem and then engage in dialogue about feelings or b) collect pre- and post-observational data regarding the child’s responses.

4) Puppets: This intervention is helpful in allowing children to use dramatic play to express their feelings, recount a story or “restory” prior negative events. It can be particularly useful when the caregiver is actively involved in the puppet intervention. Puppets can be of the caregivers’ own making or ones that are available in the clinical room. Smaller and isomorphic puppets work better with infants and toddlers, whereas 3- and 4-year-old children are more likely to respond to animal-shaped and larger puppets.

5) Anatomically and culturally correct figurines: These figurines can be useful in cases of physical and sexual abuse because children are more likely to provide an accurate accounting when directed to engage in dramatic play. This intervention allows children to reenact situations that they have experienced. Additionally, it offers opportunities for children to point to parts of the body on the figurines as well as on themselves. This activity can provide the counselor with an assessment of the child’s developmentally appropriate knowledge about sexuality.

6) Dollhouse: This intervention offers a physical example of the home that can be used to explain what happens in the home from the child’s perspective. Use of a dollhouse can aid in accessing the child’s memories more easily based on familiarity with household items rather than starting from scratch. This activity allows counselors to be either:

  • Directive with the child, using prompts such as, “Tell me what happens in this room” (while pointing to a specific room in the dollhouse)
  • Nondirective with the child, permitting the child to have free-flowing play with the items in the dollhouse (while making observational notes)

7) Play dough (modeling clay): Modeling clay provides a kinesthetic, moldable medium that children can use to contextualize and express feelings involving sensory experiences. This intervention permits children to create representations of their family members by providing definition to body parts and facial expressions, and thus connecting emotions, experiences and people to the critical event. Play dough activities allow counselors to direct children to mold important people (both family members and nonfamily members) in their lives.

8) Freehand drawing: This activity offers children the opportunity to creatively express what is happening for them in the moment. Tools for this activity are based on the child’s developmental level and might include crayons, markers, pens, pencils or chalk, depending on the child’s age and motor skills. Counselors can use this activity to promote comfort, connection, nurturance and fun for children.

9) Kinetic family/human figure drawing: Kinetic family drawing is a more directive technique that allows children to articulate how they see themselves in relation to other family members. This activity allows for dialogue between the parent and child in terms of perspectives of the family. The counselor offers paper and drawing instruments and directs the child to draw a picture of her or his family. (Note: Try to avoid stick figures, depending on the age of the child.)

10) In vivo parent-child observation and feedback: This intervention permits the counselor to assume an observer role as the parent and child interact. It can be either directive or nondirective. This activity allows for a real-time view of the interaction quality between the parent and child, providing insight into parenting style and skills as well as attachment issues. In vivo observations afford counselors the opportunity to prepare the clinical room with play materials and direct the parent to engage with the child (or, in a nondirective way, allow the parent and child to interact without instructions). Thus, the counselor can step back to observe (either in the clinical room or in an adjoining room with a one-way mirror). If the counselor is in the room, she or he can provide instant feedback and redirection, if necessary.

It should be noted that when working with preverbal children, counselors should rely on nonverbals such as body language, facial expressions, physiological responses and the child’s attention and focus. Also, be aware that children’s comprehension develops earlier than their language abilities. It is important to remember that children understand more than they can communicate.

Extending our reach

The counseling profession is poised to serve as a leading provider of much-needed services to young children. Our focus on prevention, environmental context, development and wellness makes us uniquely trained to assess, intervene with and investigate clinical issues in early childhood. The benefits for us as a profession are numerous and extensive.

First, by incorporating a focus on young children, we can increase our role definition by providing psychological consultation to children, parents, and child care providers in day care centers (such as Head Start) and preschools. Second, we move from the implicit to the explicit. Many practicing counselors are already working with young children in their agencies, schools and private practices. However, without counselor educators and policymakers explicating guidelines for practice, the profession lacks a systematic response to ensure application of evidence-based interventions. Third, we can expand our involvement in addressing the needs of this clinical population by securing grants from federal agencies and private foundations; attending think tanks and conventions where other health professionals are gathering to discuss the needs of young children; and advocating for increased coordination of service providers across all service delivery platforms and agencies. Finally, we can advocate for ourselves by becoming more visible within the larger health care community.

Recommendations: Existing courses in counselor education need to incorporate a paradigm that includes training specifically geared toward clinical populations from birth to age 5. The major challenge within this discipline is how to transform base-level skills into effective techniques and interventions for young clients.

School counselors especially need to have specialized skills and training so they are equipped with tools that acknowledge characteristics and cultural nuances that are specific to child populations. Allowing graduate students to become familiar with the pediatric population early in their training begins the process of conceptualizing young children in the context of a holistic, strength-based and culture-centered approach.

Some professionals have offered a solution to this dilemma by suggesting a framework that incorporates exposure to a variety of populations or the use of various subspecialties. In such a framework, counselor educators systematically incorporate broad content knowledge of specialized populations that is applied throughout the curriculum. Family courses could focus on the specific issues that pediatric members of the family system face and how these issues affect the entire family’s functioning. In addition, family courses could focus on interventions geared toward young children that incorporate the entire family, hence aiding the family to function more effectively. Counseling courses on theory and technique might add discussions on how to incorporate young child development and issues into concepts and interventions that are specific to various counseling theories.

Finally, to further develop our understanding of what practicing counselors actually do when working with young children, it is important to perform additional counseling research. One way of advancing our knowledge in this area might be the use of a Delphi study. This systematic approach, which would gather a panel of experts through a nominations process, could be used to generate ideas, gain consensus and identify opinions of a wide range of counseling professionals without face-to-face interaction. This method could provide a means of bridging research and practice to reach a common understanding of what steps can be taken to explore our conceptualization and assessment of and intervention with young children.

In sum, counselors have the ideal training to work closely with young clients and to provide culturally appropriate interventions to address the unique needs of this client population. Use of developmentally informed and ecosystemic frameworks will allow counselors to be accurate in their conceptualization and treatment of young children.

 

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Cirecie A. West-Olatunji serves as associate professor in counseling at Xavier University of Louisiana (XULA) and as director of the XULA Center for Traumatic Stress Research. She is a past president of the American Counseling Association and the Association for Multicultural Counseling and Development (AMCD). Internationally, she has provided consultation and training in southern Africa, the Pacific Rim and Europe. Contact her at colatunj@xula.edu.

Jeff D. Wolfgang is an assistant professor in the Department of Counseling in the College of Education at North Carolina A&T State University. His research focuses on multigenerational effects of trauma on young children and their families. Contact him at jdwolfgang@ncat.edu.

Kimberly N. Frazier is an associate professor in the Department of Clinical Rehabilitation and Counseling at the Louisiana State University Health Sciences Center-New Orleans. Her research focuses on counseling pediatric populations, cultured-centered counseling interventions and training, systemic oppression and trauma. She is a past president of AMCD and has served as an ACA Governing Council representative. Contact her at kfraz1@lsuhsc.edu.

 

Letters to the editor: ct@counseling.org

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

 

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

Behind the Book: Wellness Counseling: A Holistic Approach to Prevention and Intervention

Compiled by Bethany Bray March 18, 2019

“Each area of an individual’s life inevitably affects other areas,” write Jonathan H. Ohrt, Philip B. Clarke and Abigail H. Conley in the preface to their new book Wellness Counseling: A Holistic Approach to Prevention and Intervention. Mental health practitioners who target a treatment plan to only one aspect of a client’s life “neglect to recognize the interplay/interconnectedness of the different components that compose the well-being of our clients.”

“When I am counseling a client and reflect on the wellness model during an intake session or goal setting, I am prompted to ask not only about the presenting concern but also about factors such as the client’s religion/spirituality; gender; and physical, emotional, social and mental well-being,” Clarke explains in the books first chapter.

With that in mind, the authors write, it is imperative that counselors are able to articulate the profession’s connection to wellness, both to their clients and to other professionals. After all, the term “wellness” is in the very definition of counseling and is “an inextricable part of our professional identity,” write Ohrt, Clarke and Conley.

 

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Ohrt is an associate professor and counselor education program coordinator at the University of South Carolina. Clarke is a licensed professional counselor and faculty member in the Department of Counseling at Wake Forest University. Conley is an assistant professor in the Department of Counseling and Special Education at Virginia Commonwealth University and an affiliate faculty member in the university’s Institute for Women’s Health.

Wellness Counseling: A Holistic Approach to Prevention and Intervention was published by the American Counseling Association in December 2018. CT Online sent the co-authors some questions via email to learn more about this resource.

 

 

Q+A: Wellness Counseling

Responses written by co-authors Jonathan H. Ohrt, Philip B. Clarke and Abigail H. Conley

 

“Wellness” is often thrown around as a buzzword in our culture. How would you define wellness as it relates to counseling?

In our book, we utilize Jane Myers, Thomas Sweeney and Melvin Witmer’s definition of wellness [from their Journal of Counseling & Development article “The Wheel of Wellness Counseling for Wellness: A Holistic Model for Treatment Planning”] to guide our approach, which is that wellness is “a way of life oriented toward optimal health and well-being, in which body, mind and spirit are integrated by the individual to live life more fully within the human and natural community.”

Building off of this definition, we conceptualize a five-domain model of wellness that connects mind, body, spirit, connection and emotion [and] that highlights the interconnectedness of these domains within the whole self. Because of this holistic approach, one small change in one area can lead to positive changes in others. Thus, a client’s strengths are just as important, if not more so, than their struggles.

Finally, a key part of a wellness counseling approach is helping a client work toward their own optimal level of harmony both within and among each domain rather than [pursue] the often elusive idea of balance.

 

In the book, you all mention that wellness goes hand in hand with prevention. What do you want counselors to know about this intersection?

Prevention models in health care (e.g., primary, secondary and tertiary prevention) and education (multitiered systems of support) start with a focus on providing preventive interventions and education to avoid problems from occurring. These models emphasize healthy behaviors, decision-making, coping strategies, and strength and resiliency building.

From a wellness perspective, counselors can focus on prevention by assessing their clients holistically and collaboratively developing goals for clients to work toward optimal physical and mental health prior to the onset of problems. Goals can include physical health goals, mental health goals and goals related to the clients’ social functioning and spirituality. Counselors who focus on wellness can also advocate for policies that help promote wellness for individuals within various systems.

 

What tips would you share to help practitioners remember to step back and take a look at the client’s whole picture and not just the presenting problem?

Wellness models are one of the most useful tools to ensure that counselors consider the whole client. Utilize wellness models for client conceptualization and during sessions with clients. This will remind you to examine the client’s presenting problem from multiple perspectives.

For example, what (if any) spiritual, physical or cognitive components factor into the presenting concern? Inviting the client to reflect in this way communicates to them the importance of viewing themselves holistically. You can then discuss client strengths across wellness areas.

Counselors can also share with clients that they utilize a wellness-based approach during the informed consent process. As a self-awareness activity to solidify the relevance of wellness, you may want to write and periodically update your own wellness plan that consists of areas for improvement, strengths and goals.

Another fun and helpful exercise for counselors is to view television shows and reflect on the multifaceted nature of the stressors and lives of the characters on the show.

 

What is a main takeaway that you would like readers to know about wellness counseling?

Readers should know that wellness counseling is an approach that can be of value to and incorporated with most any client. It is useful regardless of the type or severity of the client’s presenting concern. It can be helpful when working with children or older adults.

The challenge is to not fall into the trap of a singular view of the client. It takes effort for the counselor to delve into the various aspects of the client’s well-being. Clients might initially balk at the idea of these different components of self. But this discomfort can result in benefit to the client.

Wellness counseling is versatile because the counselor can incorporate counseling theories that are most helpful to the client while remaining within the wellness framework. Wellness counseling is client-centered [because] you are offering the client new ways of understanding and experiencing themselves and new avenues for goal achievement.

 

Would you say that wellness is a new concept in the counseling profession? How long has it been something that counselors have adopted?

Wellness has been at the core of the counseling profession throughout its history. Most counselors tend to view their clients holistically and from a developmental perspective. Melvin Witmer, Thomas Sweeney and Jane Myers developed more defined theoretical and empirical wellness models for counselors in the early 1990s and 2000s. Their models are still widely used for client assessment, conceptualization and treatment planning.

A newer trend related to wellness is the integration of behavioral health with primary care. Counselors are becoming more aware of the strong relationship between physical health and mental health. Counselors are now more likely to be part of an interdisciplinary treatment team through which physical health and mental health services are integrated and coordinated together more strategically. This model fits well with a wellness perspective because counselors can engage in interdisciplinary collaboration with other professionals to provide interventions that address the client’s holistic functioning.

 

Are there any misconceptions or misunderstandings about wellness counseling that you’d like to clear up?

The exciting thing, in our experience, is that wellness appears to be critical to the identity of most counselors we have encountered. However, we have noticed that some counselors use aspects of wellness counseling without full intentionality or struggle to describe wellness counseling.

Thankfully, counselor educators such as Jane Myers and Thomas Sweeney have developed this information. We hope to highlight and add to their work, providing counselors with skills specific to this intervention and guidelines for determining whether or not they are working within a wellness counseling approach.

 

What inspired you to collaborate and create this book? Why is it relevant and needed now?

This book came together because the three of us have had many conversations about the ways that we teach wellness counseling (both as stand-alone courses and as a component of other core counseling courses) and the need for a text that delves deeply into what a wellness-based counseling approach is conceptually and also what it looks like in practice.

We wanted to write a book that is grounded in theoretical and empirical support and also provides techniques for client assessment, case conceptualization, treatment planning and intervention.

We wholeheartedly believe that wellness is an inextricable part of our professional identities as counselors and [that it] should serve as a framework for a holistic, prevention-focused approach to clients across the life span.

 

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Wellness Counseling: A Holistic Approach to Prevention and Intervention 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 ext. 222.

 

Hear more on this topic in a session with the co-authors at the ACA Conference & Expo in New Orleans later this month. Ohrt, Clarke and Conley will present a session on wellness counseling Friday, March 29 at 4 p.m. Find out more at counseling.org/conference

 

 

 

 

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Bethany Bray is a staff writer and social media coordinator 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.

 

Team sports vs. solo exercise: Which is better for your mental health?

By Bethany Bray December 3, 2018

Professional counselors often recommend exercise to clients as a way to improve mood and overall wellness. In addition to boosting serotonin, a neurotransmitter connected to feelings of well-being, exercise offers the chance to unplug from the busyness of daily life and process one’s thoughts.

A recent journal study in The Lancet Psychiatry takes that recommendation one step further, connecting team sports to improved mental health. A cohort of researchers studied four years of recent survey data from more than 1 million American adults.

They found that individuals who exercised experienced 43 percent fewer days of poor mental health in a one-month period than did people who didn’t exercise at all. Individuals who experienced the greatest mental health benefits, however, were those who participated in team sports, followed by those who rode bicycles or did aerobic and gym activities (in durations of 45 minutes, three to five times weekly).

Jude and Julius Austin, American Counseling Association members who played soccer both in college and at the professional level, stress that the study’s correlational findings do not mean causation.

“We think further research needs to be done regarding the lived experience of athletes in team sports who struggle with mental health issues,” said the brothers in a co-written statement to Counseling Today on the Lancet findings.

Although mental health improvements are not caused by exercise, physical activity does, when done appropriately, have biological, cognitive and social benefits — which Jude, an assistant professor in the counseling program at the University of Mary Hardin-Baylor in Texas, and Julius, an assistant professor in the marriage and family therapy and counseling studies program at the University of Louisiana Monroe, say they experienced as soccer players.

“It is exciting to see [researchers] investigating things we believe most athletes can collectively, albeit anecdotally, agree on,” wrote Jude, a licensed professional counselor in residency and Julius, a provisionally licensed professional counselor. “In our experience playing team sports, it feels great to survive a particularly tough practice. Pushing ourselves through seemingly impossible physical tasks with others reinforced that we have everything we need to handle life’s challenges. There is something healing about being swept away by the team’s mentality during a game; pressing or absorbing pressure, counterattacking or keeping possession, the ebb and flow of defense to offense, being in the zone. Even if it’s only for a moment, those sweeping moments were where we received social support, affirmation, genuineness, empathy and unconditional positive regard. These are all therapists’ offered conditions in an effective therapeutic relationship. We could not say this with empirical certainty, but we would imagine that receiving these conditions from a team can cause lessening of mental health issues.”

ACA member Sarah Fichtner, a former Division I women’s soccer player for the University of Maryland (UMD), has mixed feelings about the Lancet study. While there is little doubt that exercise in general benefits both mental and physical health, it can be taken to the extreme when sports are played at a high level, she says.

“I am a firm believer that exercise improves an individual’s mental health, as it produces feel-good endorphins and releases chemicals such as norepinephrine which alleviate stress and anxiety,” Fichtner says. “As an exercise and health enthusiast myself, there is not a doubt in my mind that exercise has many positive implications. However, I am a bit skeptical of the [Lancet] findings pertaining to team sports. I do see the benefits of exercise groups [in] that they provide accountability, comradery and support, but in terms of competitive team sports — particularly at the collegiate level — the environment is extremely different.”

Fichtner is a counselor intern at Hackensack Meridian Behavioral Health and is working on completing a master’s degree in clinical mental health counseling at Kean University in New Jersey. After her experience as a DI athlete, she calls for balance when it comes to competition and team sports.

“During my time as a student-athlete and captain at the University of Maryland, I saw firsthand the detrimental consequences of the collegiate world. When a player is recruited to play at the DI level, he or she is expected to perform. Coaches have one goal in mind, and that is to win,” she explains. “Practices are intense, to say the least, and the idea of healthy competition goes out the window. A player is competing against his or her teammates every day to secure a starting position. They are competing to be the fastest, fittest, slimmest and most technical or tactical player. And every day, their coaches are telling them, ‘You are not good enough,’ ‘You need to lose five more pounds to be in the running for a starting position,’ ‘Your teammates are working harder than you’ and ‘Ask your teammate so-and-so for help. She is outperforming you. She has great skills.’ This high-intensity environment can lead to many mental health challenges such as eating disorders, anxiety, depression and low self-esteem, which I witnessed during my four years at UMD. Thus, when I think about team sports, specifically at the collegiate level, the word balance comes to mind.”

“Aside from the intense environment, there were many positives takeaways from my time as a student-athlete,” Fichtner adds. “I made lifelong friendships, competed at the highest level of collegiate sports, was privileged to visit many states, had top-notch gear, learned important life lessons and would do it all over again in a heartbeat. Nevertheless, now as a mental health counselor, I see the collegiate world through a different lens. Many of the challenges we athletes faced on a daily basis seemed both normal and absolute. But now as I grow both personally and professionally, I realize that colleges need to establish a balance between a healthy competitive environment, where athletes are pushed and held accountable, and a debilitating, harmful environment, in which athletes are placed in harm’s way [of] mental health challenges. Balance is key to any exercise regimen, especially in the collegiate world.”

 

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Read the Lancet study in full: thelancet.com/journals/lanpsy/article/PIIS2215-0366(18)30227-X/fulltext#seccestitle10

 

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ACA members: Interested in exploring connections between sports and mental health? Join ACA’s Sports Counseling Interest Network.

 

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

 

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

 

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

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.