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I'm always available to chat or exchange ideas or to just listen!
Where Can I Go For Help?
Where you go for help will
depend on who has the problem (an adult or child) and the nature of the
problem and/or symptoms.
Often, the best place to start
is your local Mental Health Association. Check your Yellow Pages for a listing or call the National Mental Health Association
at 800/969-NMHA.
Other suggested resources:
- Your local health departments
Mental Health Division. These services are state funded and are obligated to first serve individuals who meet "priority population criteria" as defined by the state Mental Health Dept. There may be waiting lists and not
all individuals may be eligible for services. In some jurisdictions local funding is provided for additional services.
- Other mental health organizations
- Family physician
- Clergyperson
- Family services agencies,
such as Catholic Charities, Family Services, or Jewish Social Services
- Educational consultants or
school counselors
- Marriage and family counselors
- Child guidance counselors
- Psychiatric hospitals accredited
by the Joint Commission on Accreditation of Health Care Organizations
- Hotlines, crisis centers
and emergency rooms (call 411 for Directory Assistance)
Which Mental Health Professional
Is Right For Me?
There
are many types of mental health professionals. Finding the right one for you may require
some research. Often it's a good idea to first describe the symptoms and/or problems to your family physician or clergy. He
or she can suggest the type of mental health professional you should call.
  Types of Mental Health Professionals
- Psychiatrist - medical
doctor with special training in the diagnosis and treatment of mental and emotional illnesses. Like other doctors, psychiatrists
are qualified to prescribe medication.
Qualifications: should
have a state license and be board eligible or certified by the American Board of Psychiatry and Neurology.
- Child/Adolescent Psychiatrist
- medical doctor with special training in the diagnosis and treatment of emotional and behavioral problems in children. Child/Adolescent
psychiatrists are qualified to prescribe medication.
Qualifications: should
have a state license and be board eligible or certified by the American Board of Psychiatry and Neurology.
- Psychologist - Counselor
with an advanced degree from an accredited graduate program in psychology and 2 or more years of supervised work experience.
Trained to make diagnoses and provide individual and group therapy.
Qualifications: a state
license.
- Clinical Social Worker
- Counselor with a masters degree in social work from an accredited graduate program. Trained to make diagnoses & provide
individual and group counseling.
Qualifications:
state license; may be member of the Academy of Certified Social Workers.
- Licensed Professional Counselor
- Counselor with a masters degree in psychology, counseling or a related field. Trained to diagnose and provide individual
and group counseling.
Qualifications: state
license
- Mental Health Counselor
- Counselor with a masters degree and several years of supervised clinical work experience. Trained to diagnose and provide
individual and group counseling.
Qualifications: certification
by the National Academy of Certified Clinical Mental Health Counselors.
Qualifications: state
license
- Nurse Psychotherapist
- A registered nurse who is trained in the practice of psychiatric and mental health nursing. Trained to diagnose and provide
individual and group counseling.
Qualifications: certification,
state license.
- Marital and Family Therapist
- A counselor with a masters degree, with special education and training in marital and family therapy. Trained to diagnose
and provide individual and group counseling.
Qualifications: state
license
- Pastoral Counselor
- Clergy with training in clinical pastoral education Trained to diagnose and provide individual and group counseling.
Qualifications: Certification
from American Association of Pastoral Counselors.
Counselors
Significant Points
- School
counselors must be certified and other counselors must be licensed to practice in all but 2 states. A master’s
degree generally is needed to become a licensed counselor.
- Job
opportunities for counselors should be very good because job openings are expected to exceed the number of graduates
from counseling programs.
- State
and local governments employ about 4 in 10 counselors and the health services industry employs most of the others.
Nature of the Work
Counselors assist
people with personal, family, educational, mental health and career decisions and problems. Their duties depend on the individuals
they serve and on the settings in which they work.
Educational,
vocational and school counselors provide individuals and groups with career and educational counseling. In school settings
- elementary through post-secondary - they usually are called school counselors and they
work with students, including those with academic and social development problems and those with special needs.
They advocate for students and work with other individuals and organizations to promote the academic,
career, personal and social development of children and youths.
School
counselors help students evaluate their abilities, interests, talents and personality characteristics in order to develop
realistic academic and career goals.
Counselors
use interviews, counseling sessions, interest and aptitude assessment tests and other methods to evaluate and advise students.
They also operate career information centers and career education programs.
High school counselors
advise students regarding college majors, admission requirements, entrance exams, financial aid, trade or technical schools
and apprenticeship programs. They help students develop job search skills, such as resume writing and interviewing techniques.
College
career planning and placement counselors assist alumni or students with career development and job-hunting techniques.
Elementary school counselors
observe younger children during classroom and play activities and confer with their teachers and parents to evaluate the children’s
strengths, problems, or special needs.
In conjunction with teachers and administrators, they make sure that the curriculum addresses both the
academic and the emotional development needs of students. Elementary school counselors do less vocational and academic counseling than do secondary school counselors.
School counselors at all levels
help students to understand and deal with social, behavioral and personal problems. These counselors emphasize preventive and developmental counseling
to provide students with the life skills needed to deal with problems before they occur and to enhance students’ personal, social and academic growth.
Counselors provide
special services, including alcohol & drug prevention programs and conflict resolution classes. They also try to identify cases of domestic abuse and other family problems that can affect a student’s development.
Counselors interact with students
individually, in small groups, or with entire classes. They consult and collaborate with parents, teachers, school administrators,
school psychologists, medical professionals and social workers in order to develop and implement strategies to help students
be successful in the education system.
Vocational counselors who
provide mainly career counseling outside the school setting are also referred to as employment counselors or career counselors. Their chief focus is helping individuals with career
decisions.
Vocational counselors
explore and evaluate the client’s education, training, work history, interests, skills and personality traits and arrange for aptitude and achievement tests to assist the client in making career decisions. They also work with individuals
to develop their job-search skills and they assist clients in locating and applying for jobs.
In
addition, career counselors provide support to persons experiencing job loss, job stress, or other career transition issues.
Rehabilitation
counselors help people deal with the personal, social and vocational effects of disabilities. They counsel people with
disabilities resulting from birth defects, illness or disease, accidents, or the stress of daily life.
They evaluate the strengths and limitations of individuals, provide personal and vocational counseling and arrange for medical care,
vocational training and job placement. Rehabilitation counselors interview both individuals
with disabilities and their families, evaluate school and medical reports and confer and plan with physicians, psychologists,
occupational therapists and employers to determine the capabilities and skills of the individual.
Conferring with the client, they develop a rehabilitation program that often includes training
to help the person develop job skills. Rehabilitation counselors also work toward increasing the client’s capacity to live independently.
Mental health counselors
work with individuals, families and groups to address and treat mental & emotional disorders and to promote optimum mental
health.
They're
trained in a variety of therapeutic techniques used to address a wide range of issues, including:
Mental health counselors
often work closely with other mental health specialists, such as:
- psychiatrists
- psychologists
- clinical social workers
- psychiatric nurses
- school counselors
(Information on
physicians & surgeons, psychologists, registered nurses & social workers appears elsewhere in the Handbook.)
Substance abuse and behavioral disorder counselors help people who have problems with alcohol, drugs, gambling and eating disorders. They counsel individuals who are addicted to drugs, helping them to identify behaviors and problems related to their addiction.
They also conduct programs aimed at preventing addictions from occurring in the first place. These counselors hold sessions designed for individuals, families, or groups.
Marriage and family therapists
apply principles, methods and therapeutic techniques to individuals, families, couples, or organizations in order to
resolve emotional conflicts.
In doing so, they modify people’s perceptions and behaviors, enhance communication and understanding among family members and help to prevent family and individual crises.
Marriage and
family therapists also may engage in psychotherapy of a nonmedical nature, make appropriate referrals to psychiatric
resources, perform research and teach courses about human development and interpersonal relationships.
Other
counseling specialties include:
- gerontological: A
gerontological counselor provides services to elderly persons and their families when they face changing lifestyles as they grow older.
- multicultural: A multicultural counselor helps employers adjust to an increasingly diverse workforce.
- genetic counseling: Genetic counselors provide information and support to families who have members with birth defects or genetic disorders and to families who may be at risk for a variety of
inherited conditions.
These counselors identify families at risk, investigate the problem that is present in the
family, interpret information about the disorder, analyze inheritance patterns and risks of recurrence and review available
options with the family.
Training, Other Qualifications and Advancement
All
States require school counselors to hold a State
school counseling certification and to have completed at least some graduate course
work; most require the completion of a master’s degree.
Some States require public school counselors to have both counseling and teaching certificates and to have had some teaching experience
before receiving certification.
For counselors based outside of schools, 48 States and
the District of Columbia have some form of counselor licensure that governs their practice
of counseling.
Requirements typically
include:
-
completion of a master’s degree in counseling
- the accumulation of 2 years or 3,000 hours of supervised clinical
experience beyond the master’s degree level the passage
of a State-recognized exam
-
adherence to ethical codes and standards
-
completion of annual continuing education requirements
Counselors must be aware of educational and training requirements that are often very detailed and that vary by area and by counseling specialty.
Prospective counselors should
check with:
- State and local governments
- employers
- national voluntary certification organizations
in order to determine which requirements apply.
As mentioned, a master’s degree is typically required to be licensed
as a counselor. A bachelor’s degree often qualifies a person to work as a counseling aide,
rehabilitation aide, or social service worker.
Some
States require counselors in public employment to have a master’s degree; others accept a bachelor’s
degree with appropriate counseling courses.
Counselor
education programs in colleges and universities usually are found in departments of education or psychology. Fields
of study include:
What Does a School Counselor Do?
Parents,
the press, administrators and the general public often wonder just what it is that school counselors
do on a daily basis. Gone are the days of school counselors sitting in their office simply
handing out college applications, making schedule changes for students who want to drop a class or meeting with the troublemakers
in the school.
Today's school
counselors are vital members of the education team. They help all students in the areas of academic achievement, personal/social
development and career development, ensuring today's students become the productive, well-adjusted adults of tomorrow. Learn more about the school counselor's role.
The Need for School Counselors
School counselors are an important part of the educational leadership team and provide valuable assistance to students regardless of whether they work in an elementary school or middle school, high school or beyond.
Why Elementary School Counselors?
Why Middle/Jr. High School Counselors?
Why Secondary School Counselors?
Why Post-secondary School Counselors?
Why School Counseling Directors/Coordinators?
Appropriate / Inappropriate
School Counseling Program Activities
School counselors
should spend most of their time in direct service to and contact with students. School counselors' duties are focused on the
overall delivery of the total program through guidance curiculum, individual student planning and responsive services.
A
small amount of their time is devoted to indirect services called system support. Schools should eliminate or reassign certain inappropriate program tasks, if possible, so school counselors can focus
on the prevention needs of their programs.
View a chart of appropriate and inappropriate school counseling tasks, as well as a suggested use of time.
ASCA Highlights Professional Trends in Serving Student Needs
FOR IMMEDIATE RELEASE
February 6, 2006
Contact: Jill Cook (703) 683-2722 Ext.105 Elaine Yin (202) 857-2202
National
School Counseling Week:
American School Counselor Association Highlights
Professional Trends in Serving Students’
Needs
School Counselors’ Role Expands to
Address Challenges of Today’s Students
(Alexandria, VA) The role of school counselors is expanding, according to the American School Counselor Association (ASCA)
as it celebrates National School Counseling Week, Feb. 6-10. Today, counselors are addressing myriad personal and social issues
that can become barriers to learning.
On top of the
drive to make good grades, students contend with:
To ensure that students achieve both academically and socially, school counselors
are the primary and often the only in-school professional assisting them with these challenges.
In fact, a recent study shows that school counselors are spending more
than 1/2 of their time addressing students’
mental health issues.
The theme of this year’s
School Counseling Week is
"Changing Lives, Building Futures.”
“Every
day, school counselors address barriers to learning and academic success,” said. Barbara Blackburn, ASCA president. “Now more than ever, it’s important for parents and counselors to work together to address fears, anxieties and other challenges in a young person’s life.”
Numerous studies document the nature of pressures facing today’s students:
School
counselors can make a measurable impact in every student’s life. Professional
school counselors are trained in both educating and counseling.
Research literature has documented the effectiveness of school counselors
and school counseling programs in such areas as:
“School
counselors are the first line of support for students. Students can’t achieve academically when they can't cope with social and emotional problems,” said Richard Wong, ASCA executive director.
“School counselors
can help guide students in their journey through childhood and adolescence.”
ASCA encourages parents to maintain an open dialogue with their child’s counselor and establish contact in-person, or via phone and email at least 3 times per school year.
A strong parent-counselor relationship remains the single best tool in addressing student concerns before they become major issues, according to ASCA.
The American School Counselor
Association (ASCA) supports the school counseling profession by educating the public about the positive and measurable impact school counselors have on student success. The organization also supports school counselors' efforts to improve each student's academic, personal, social and career
development so he or she excels in school and is prepared to lead a fulfilling life as a responsible member of society.
ASCA provides professional
development, publications, research and advocacy to more than 18,000 professional school counselors around the world. For
more information about ASCA and its mission, visit www.SchoolCounselor.org.
and the snake came too
June Platts highlights the realities and the challenges that can arise when working with children and young people in private practice.
Couples Counseling and
Family Therapy
These 2 similar
approaches to therapy involve discussions and problem-solving sessions facilitated by a
therapist sometimes with the couple or entire family group, sometimes with individuals.
Such therapy can
help couples and family members improve their understanding of and the way they respond to, one another. This type of therapy can resolve patterns
of behavior that might lead to more severe mental illness.
Family therapy
may be very useful with children and adolescents who are experiencing problems.
Coping with serious mental illness is hard on marriages and families. Family therapy can help educate the individuals
about the nature of the disorder and teach them skills to cope better with the effects of having a family member with a mental illness such as how to deal with feelings of anger or guilt.
In addition, family therapy can help members identify and reduce factors that may trigger or worsen the disorder.
Family Therapy Can Combat Conduct Disorders
By Peggy Peck, Senior Editor, MedPage Today
August 11, 2005
Review
NEW
YORK, Aug. 11 - Family therapy can help quell substance abuse and conduct disorders in children and adolescents, but isn't as effective when the diagnosis is
attention deficit hyperactivity disorder (ADHD), researchers said here today.
A 10-year review of published research found that 2 types of family therapy, parent management training and
behavioral family therapy, are especially effective for conduct disorders, said Allan Josephson,
M.D., of Bingham Child Guidance in Louisville.
Dr. Josephson,
co-author of the review, which will be published in the September issue of the Journal of Child & Adolescent Psychiatry,
presented the findings at a back-to-school health briefing sponsored by the American Medical Association and the National
PTA.
Parent-management training teaches parents techniques such as positive reinforcement and working with children to develop problem-solving skills. Dr. Josephson said that studies suggests that parent-management training can be an effective
for conduct disorders for up to 14 years - long enough for a child to complete elementary and high school.
Behavioral family therapy
is a similar technique but it also incorporates "into treatment a variety of family, parent and child
factors that have been implicated as leading to disruptive disorders (e.g. parental stress, cognitions about the child, child temperament)."
The literature review suggested that ADHD core symptoms are better controlled by a combination of pharmacotherapy and board based interventions that include psychosocial
interventions and may include family therapy.
Likewise, there's no evidence that family
therapy is effective for treatment of depression although some "new treatments for depression and anxiety are emerging that focus on attachment, parenting practices and general family functioning," the authors wrote. These new studies "suggest that family treatments
or treatment augmented by family treatments are effective for depression and anxiety," they said.
Finally, Dr. Josephson said that family-based therapy
may help in some of the current concerns about the side effects of pharmacotherapy, such as suicidal ideation. "When physicians and parents are partners in monitoring patients' safety, the family serves as a safety net that can facilitate several treatment goals."
Related articles:
Counseling for Addictions Recovery
Gambling addiction causes misery that can't be confined to the arcades and fruit machines that fuel it - yet it mostly slips through the official nets
of funding and resources. Clare Pointon interviews some of those involved in addressing the problem
-
rehabilitation counseling
-
agency or community counseling
-
clinical mental health counseling
-
counseling psychology
-
career counseling
-
related fields
Courses
are grouped into 8 core areas:
In
an accredited master’s degree program, 48 to 60 semester hours of graduate study, including a period of supervised
clinical experience in counseling, are required.
Graduate programs in career,
community, gerontological, mental health, school, student affairs and marriage and family counseling are accredited by the
Council for Accreditation of Counseling and Related Educational Programs (CACREP).
While completion
of a CACREP - accredited program isn't necessary to become a counselor, it makes it easier to fulfill the requirements
for State licensing.
Another
organization, the Council on Rehabilitation Education (CORE), accredits graduate
programs in rehabilitation counseling. Accredited master’s degree programs include
a minimum of 2 years of full-time study, including 600 hours of supervised clinical internship experience.
Some counselors elect to be nationally certified by the
National Board for Certified Counselors, Inc. (NBCC), which grants the general practice
credential “National Certified Counselor.”
To be
certified, a counselor must hold a master’s degree with a concentration
in counseling from a regionally accredited college or university; must have at least 2 years of supervised field experience
in a counseling setting (graduates from counselor education programs accredited by CACREP
are exempted); must provide two professional endorsements, one of which must be from a recent supervisor;
and must have a passing score on the NBCC’s National Counselor Examination for Licensure and Certification (NCE).
This national certification is voluntary and is distinct from State licensing.
However, in some States, those who pass the national exam are exempted from taking a State certification exam. NBCC also offers
specialty certifications in school, clinical mental health and addiction counseling, which
supplement the national certified counselor designation.
These specialty certifications require passage of a supplemental exam. To maintain their
certification, counselors retake and pass the NCE or complete 100 credit hours of acceptable continuing education every
5 years.
Another
organization, the Commission on Rehabilitation Counselor Certification, offers voluntary national certification
for rehabilitation counselors. Some employers may require rehabilitation counselors to be nationally certified.
To become certified,
rehabilitation counselors usually must graduate from an accredited educational program,
complete an internship and pass a written examination. (Certification requirements vary
according to an applicant’s educational history.)
Employment
experience,( i.e., is required for those with a counseling degree in a specialty
other than rehabilitation.) After meeting these requirements, candidates are designated “Certified Rehabilitation
Counselors.”
To maintain their certification, counselors must successfully retake
the certification exam or complete 100 credit hours of acceptable continuing education every 5 years.
Other
counseling organizations also offer certification in particular counseling specialties.
Usually, becoming certified is voluntary, but having certification may enhance one’s job prospects.
Some employers
provide training for newly hired counselors. Others may offer time off or provide help with tuition if it is needed to complete
a graduate degree. Counselors must participate in graduate studies, workshops and personal
studies to maintain their certificates and licenses.
Persons interested in counseling should have a strong desire to help others and should possess the ability to inspire respect, trust and confidence. They should be able to work independently or as part of a team. Counselors must follow the code of ethics associated with their respective
certifications and licenses.
Prospects for advancement vary by counseling field. School counselors can move to a larger school; become directors or supervisors of counseling,
guidance, or pupil personnel services; or, usually with further graduate education, become counselor
educators, counseling psychologists, or school administrators. (Psychologists and education administrators are covered elsewhere
in the Handbook.)
Some
counselors choose to work for a State’s department of education. For marriage
and family therapists, doctoral education in family therapy emphasizes the training of supervisors, teachers, researchers
and clinicians in the discipline.
Counselors can become supervisors or administrators in their agencies. Some counselors move into research, consulting,
or college teaching or go into private or group practice.
Making the call for an appointment
Spend a few minutes
talking with the secretary or receptionist to ask the following questions:
- ask about their approach to working with patients, their philosophy,
whether or not they have a specialty or concentration (some psychologists for instance
specialize in family counseling, or child counseling, while others specialize in divorce or coping with the loss of a loved one.) If you feel comfortable talking to the counselor or doctor, the next step is to make an appointment.
On your 1st visit, the counselor or the doctor, will want to get to know you and why you called him
or her. The counselor will want to know:
- what you think the problem is
- about your life
- what you do
- where you live
- with whom you live
It's also common to be asked about your family and friends. This information helps the professional to
assess your situation and develop a plan for treatment.
If you don't feel comfortable with the professional after the first, or even several visits, talk about your feelings at your next meeting; Don't be afraid to contact another counselor. Feeling comfortable with the professional you choose is very important to the success of your treatment.
How It's Done
counselling & psychotherapy: is there a difference?
Are counselling and psychotherapy the same or are they different? And how much does it matter? This question
lies at the heart of a debate, heated up by the prospect of professional regulation. By Clare Pointon
Resources for the uninsured:
- Community-based resources:
Many communities have community mental health centers (CMHCs). These centers offer a range of mental health treatment &
counseling services, usually at a reduced rate for low-income people. CMHCs generally require
you to have a private insurance plan or to be a recipient of public assistance.
- Pastoral Counseling: Your
church or synagogue can put you in touch with a pastoral counseling program. Certified pastoral counselors, who are ministers
in a recognized religious body, have advanced degrees in pastoral counseling, as well as professional counseling experience.
Pastoral counseling is often provided on a sliding-scale fee basis.
- Self-help groups: Another
option is to join a self-help or support group. Such groups give people a chance to learn about, talk about, & work on their common problems, such as alcoholism, substance abuse, depression, family issues & relationships. Self-help groups are generally free & can be found in virtually every community in America. Many people
find them to be effective.
- Public assistance: People
with severe mental illness may be eligible for several forms
of public assistance, both to meet the basic costs of living & to pay for health care. Examples of such programs are Social
Security, Medicare & Medicaid.
- Social Security has 2 types
of programs to help individuals with disabilities. Social Security Disability Insurance provides benefits for those individuals
who have worked for a required length of time & have paid Social Security taxes. Supplemental Security Income provides
benefits to individuals based on their economic needs (Social Security Administration, 2002).
- Medicare is America's primary
Federal health insurance program for people who are 65 or older & for some with disabilities who are under 65. It provides
basic protection for the cost of health care. Two programs exist to help people with low incomes receive benefits: the Qualified
Medicare Beneficiary (QMB) & the Specified Low-Income Medicare Beneficiary (SLMB) programs.
- Medicaid pays for some health
care costs for America's poorest & most vulnerable people. More information about Medicaid & eligibility requirements is available at local welfare & medical assistance offices.
Although there are certain Federal requirements, each State also has its own rules & regulations for Medicaid.
For more information about how to pay for mental health care, contact:
National Mental Health Information
Center
P.O. Box 42557
Washington, DC 20015
Telephone: 800-789-2647
(TDD): 866-889-2647
E-mail: info@mentalhealth.org
www.mentalhealth.samhsa.gov
some reasons for considering counseling
Some examples of distorted or negative thinking:
perfectionism: If you're not perfect, you must be awful. If you get a B on a test, you think that you're an idiot for not getting an A. This type of thinking is overwhelmingly characteristic of how perfectionists think about every aspect of their life & their own selves.
discounting the positive: You finish a difficult project. Your boss
congratulates you for doing a great job & you think, "Any idiot could have done just as well." This type of thinking can often originate from very low self esteem.
arbitrary inference: You think that something is wrong without any evidence. Someone doesn't say hello to you so you assume that the person is mad at you.
externalization of self-worth: You're
a worthwhile human being only if other people say so.
what
you can do
"Our lives are shaped by our thoughts, we become what we think," said the Buddha. Modern psychotherapists agree.
How we think about our lives influences our feelings and our actions.
Dwelling on negative thoughts accentuates feelings of depression and may worsen some of the chemical imbalance in the brain. Adapting a more positive attitude can actually help you to feel better.
- Change "What If's" to "So What".
- What am I telling myself
that is scaring me?
- The more I do, the more I
can do.
- I've done it before, I CAN
do it again!
- I am the same person, here
or in my safe place.
- I can handle it, nothing
terrible will happen.
- In reality, there is nothing
that can hurt me here.
- The anxiety can only go so high and then it comes down.
Even Minimal Counseling Can Change Kids' Eating Habits
Study showed children ate less fat, salt, after just five sessions
MONDAY,
Sept. 12 (HealthDay News) - Children from families at high risk for heart disease ate healthier after receiving just 5 dietary counseling sessions spread out over 3 years,
Finnish researchers found.
Family-based counseling can achieve great goals in weight
reduction among children, but most successful programs have involved 6 months to a year of intense counseling,
the researchers point out.
However, these new findings show that "even when you have very
limited resources and you can only do 5 interventions with these families, you're starting to see movement
at least in the diet arena," said expert Sylvia Moore, director of a medical education program at the University of Wyoming.
Reporting in the current issue of the American Journal of
Health Behavior, researchers at Finland's University of Turku tracked the dietary change of 432 school-aged
children. The children's families were chosen using hospital records to determine a history of heart disease, stroke or high cholesterol.
The investigators found that, after the 5 counseling sessions,
children reported eating less fat and salt than other youngsters.
More
information
The
National Institutes of Health has more about heart disease and diet (www.nlm.nih.gov ).
it's in the news...
Cognitive Therapy Helps Ease Back Pain :The technique is as effective as physical therapy, study finds
Cognitive Behavioral Therapy: The
basics
John Winston Bush, PhD - New
York Institute for Cognitive & Behavioral Therapies
Cognitive behavior therapy
is a clinically and research proven breakthrough in mental health care. Hundreds of studies by research psychologists and
psychiatrists make it clear why CBT has become the preferred treatment for conditions such
as these.
- Difficulty establishing or staying in relationships
- Problems with marriage or other relationships you're already
in
- Job, career or school difficulties
Just what is CBT? How
does it work?
Cognitive behavior therapy*
combines 2 very effective kinds of psychotherapy cognitive therapy and behavior therapy.
Behavior therapy
helps you weaken the connections between troublesome situations and your habitual reactions to them. Reactions such as fear, depression or rage and self-defeating or self-damaging behavior. It also teaches you how to calm your mind and body, so you can feel better, think more clearly and make better decisions.
Cognitive therapy teaches
you how certain thinking patterns are causing your symptoms by giving you a distorted picture of what's going on in your life and making you feel anxious, depressed or angry for no good reason, or provoking you into ill-chosen actions.
When combined into CBT, behavior therapy and cognitive therapy provide
you with very powerful tools for stopping your symptoms and getting your life on a more satisfying track.
a quick personal note:
Some counselors will work
with you without a specific plan for treatment by simply talking through things that you have on your mind. If you are really
eager to get over your phobia, panic disorder or another anxiety disorder - ask your counselor if you can use CBT with a specific
action plan to rid yourself of the symptoms of these disorders!
If you don't ask, counseling
may get frustrating & you may think you're not making any progress!
kathleen
CBT is active therapy
In CBT,
your therapist takes an active part in solving your problems. He or she doesn't settle for
just nodding wisely while you carry the whole burden of finding the answers you came to therapy for.
You'll receive a thorough
diagnostic workup at the beginning of treatment to make sure your needs and problems have been pinpointed as well as possible.
This crucial
step which is often skimped or omitted altogether in traditional kinds of therapy
results in an explicit, understandable and flexible treatment plan that accurately reflects your own individual needs.
In many ways CBT resembles education, coaching or tutoring. Under expert
guidance, as a CBT client you will share in setting treatment goals and in deciding which techniques work best for you personally.
Structured and focused
CBT provides clear structure
and focus to treatment. Unlike therapies that easily drift off into interesting but unproductive side trips, CBT sticks to the point and changes course only when there are sound reasons for doing so.
As a CBT
client, you'll take on valuable homework projects to speed your progress. These assignments which are developed as much as possible with your own active
participation extend and multiply the results of the work done in your therapist's office.
You may also receive take-home
readings and other materials tailored to your own individual needs to help you continue to forge ahead between sessions.
What else is different about CBT?
Most people coming for therapy need to change something in their lives whether it's the way they feel, the way they act, or how other people treat them. CBT focuses on finding out just what needs to be changed and what doesn't and then works for those targeted changes.
Some exploration of people's
life histories is necessary and desirable if their current problems are closely tied to unfinished emotional business from the past, or if they grow out of a repeating
pattern of difficulty. Nevertheless, 100 years of psychotherapy have made this clear.
Past vs. present and future
Focusing on the past (& on dreams) can at times help explain a person's difficulties. But these activities
all too often do little to actually overcome them.
Instead,
in CBT we aim at rapid improvement in your feelings and moods and early changes in any self-defeating behavior you may be caught up in. As you can see, CBT is more present-centered and forward-looking than traditional therapies.
The levers of
change
The 2 most powerful levers of constructive change (apart from medication in some cases - reason being that the meds will alleviate the symptoms of the disorder & increase feelings of well-being & clarity of thinking) are these .
- Altering ways of thinking a person's thoughts, beliefs, ideas, attitudes, assumptions, mental imagery & ways of directing his or her attention for the better. This is the cognitive aspect of CBT.
- Helping a person greet the
challenges & opportunities in his or her life with a clear & calm mind & then taking actions that are likely to have desirable results. This is the behavioral aspect of CBT.
In other words,
CBT focuses on exactly what traditional therapies tend to leave out how to achieve beneficial change, as opposed to mere explanation or insight.
CBT: The therapy with by far the most research support
CBT has been very
thoroughly researched. In study after study, it has been shown to be as effective as drugs in treating both depression & anxiety.
In particular,
CBT has been shown to be better than drugs in avoiding treatment failures & in preventing relapse after the end of treatment. If you're concerned about your ability to complete treatment & maintain your gains thereafter, keep this in mind.
Other symptoms
for which CBT has demonstrated its effectiveness include problems with relationships, family,
work, school, insomnia & self-esteem.
And it's usually
the preferred treatment for shyness, headaches, panic attacks, phobias, post-traumatic stress, eating disorders, loneliness, & procrastination. It can also be combined, if needed, with psychiatric medications.
No other type of
psychotherapy has anything like this track record in outcome research.
What about drug treatment?
CBT is usually
employed by itself, without psychiatric drugs. For some people, however, drug treatment is needed to obtain a partial reduction in symptoms before CBT
can be fully effective. Usually, though not always, it's preferable to try CBT alone before
prescribing medications.
This is for several reasons:
Benzodiazepine drugs such as alprazolam (Xanax), plus certain other types of tranquilizers,
can be habit-forming if taken over a long time or in high doses. This is a complication that needs to be avoided if possible.
Despite their reputation
as wonder drugs, antidepressants such as amitryptaline (Elavil) & fluoxetine (Prozac)
work only about 65% of the time. MAOI drugs (e.g., Nardil) carry a risk
of hypertensive crisis, stroke or even death if common foods or beverages containing tyramine are unintentionally consumed.
Finally, the mood
stabilizer lithium carbonate can produce toxic reactions unless it's very carefully monitored.
In addition, research
studies have revealed these other facts about drug treatment for depression & anxiety:
- CBT & well-chosen drugs, when each is used alone, are about equally effective during the period of active treatment.
- Adding drug treatment to
CBT isn't likely to get better results than using CBT alone (except
in special cases such as the one described above).
- Treatment failure is more likely when drugs are used, typically because of side effects.
- Relapse after the end of
treatment is more likely when only drugs have been used. This is believed to be because drugs, unlike CBT, don't encourage the development of valuable coping & emotional management skills.
Questions that
are being raised about antidepressant drugs
In addition, a
number of questions have been raised about antidepressant drugs which are increasingly being prescribed for anxiety conditions as well:
- Whether widespread beliefs about their effectiveness are scientifically justified.
- The side effects & withdrawal
symptoms they can produce.
- Their safety, especially when used in combination with other psychoactive drugs.
- The theories about depression that support their use.
- Whether they really are as
likely to help as well-chosen forms of psychotherapy.
CBT is
usually brief
Most CBT patients are able to complete their treatment in just a few weeks or months even for problems that
traditional therapies often take years to resolve, or aren't able to resolve at all.
Meanwhile, for
people w/complex problems, or who are forced to live in adverse conditions beyond their control, longer-term treatment is also available.
(See discussion of factors affecting treatment length.)
How often will I be seen?
The answer to this
question depends on your individual needs, your insurance plan & the way your own therapist prefers to work.
As a rule, however,
most people can expect to begin their treatment w/weekly visits.
A few particularly
if they're in crisis may begin w/2 or more sessions a week until their condition is stabilized enough that they can safely come only once a week.
What happens further on in treatment?
Again,
the answer depends on how you're progressing & on your therapist's & your own preferences.
These are among the options that are often recommended . . .
-
Individual sessions every other week or monthly,
combined w/weekly group therapy meetings.
-
Individual sessions every other week or monthly,
without participation in group therapy.
-
A planned break of several weeks, followed by resumption
of weekly individual sessions for a period of time.
-
A trial termination of therapy w/the option of
resuming if the need develops. Quite often, a follow-up session or phone contact is scheduled for a future date.
Do it when you
need it & not when you don't
In addition, most
CBT practitioners subscribe to the principle of intermittent brief psychotherapy, as
& when needed.
In this treatment
model espoused by Dr. Nicholas Cummings, a world leader in therapeutic advancement & former president of the American
Psychological Association you don't go into therapy & (like Woody Allen) stay for year after year, regardless of whether you're making significant progress or not.
Instead, you consult
your therapist when there's a problem you need professional help w/& not in between. After all, isn't this sensible approach the one you follow w/your physician, your
dentist, your attorney or accountant & all those other professionals?
the article below is long & for some
may be alittle hard to understand. i did think it was important to portray different degrees of complicity in the types of
counseling & how important it is to find a counselor who is experienced in treating your particular type of disorder.
What is
Comprehensive
Cognitive Behavioral Therapy?
How is CCBT used to Overcome Social Anxiety Disorder?
Thomas A. Richards, Ph.D.
Director, Social Anxiety
Institute
It wasn't long
ago that very few people had heard the term "cognitive - behavioral therapy".
With the outpouring
of research in the 1980's & the studies on anxiety disorders that were published in the 1990's, the term "cognitive behavioral therapy", or CBT, gained acceptance & became well known. But even though the term itself became well known, just what
"cognitive-behavioral therapy" involved was less well understood.
Meanwhile, in study
after study, cognitive behavioral therapy began to prove to be the therapy of choice for
many mental health care problems, including depression & the anxiety disorders.
In fact, large-scale,
long-range (i.e., longitudinal) studies over the past decade have consistently shown cognitive behavioral therapy to be the only therapy that can be dependably relied upon to help
people overcome clinical anxiety disorders.
While this was
good news, some rather large questions continued to cloud the horizon. For example, each study defined CBT in a different
way & most studies were rather vague in their explanation of just what CBT was considered to be. The other big problem
was that people began to think of cognitive-behavioral therapy as a "unified" therapy, or as a therapy that was "set"
or always the same for every mental health care problem.
In fact, CBT is
a combination or a "pulling together" of any & all methods, strategies & techniques that work to help people successfully
overcome their particular emotional problems.
The cognitive part
of the therapy refers to thinking or learning & is the part of therapy that can be "taught" to the person. The person then needs to take what has been
taught, practice it at home & thru means of repetition, get that new "learning" down into the brain over & over again
so that is becomes automatic or habitual.
This is essentially
the same process as school or college learning. You're taught some new information or skills & then you learn them. When
you learn them well enough (thru repetition), this affects your memory processes (& physiologically your brains neural pathways) & allows you to begin thinking, acting & feeling differently.
This takes persistence,
practice & patience, but when a person sticks with this therapy & doesn't give up, noticeable progress begins to occur.
The behavioral
component of CBT involves participation in an active, structured therapy group, consisting of people with clinical
social anxiety. In the behavioral group, people voluntarily engage in practical activities that are mildly anxiety-causing
& proceed in a flexible, steady, scheduled manner.
By moving forward
in this manner, step by step & thru the use of repetition, the anxiety felt in social situations is gradually reduced.
The behavioral
therapy group should consist of people with social anxiety only. People w/other emotional problems shouldn't be mixed into
this group. Even an "anxiety" group will not work. Because the problems are very different from each anxiety disorder to the
other, the behavioral group & its activities would prove to be ineffective for people w/panic, generalized anxiety, or obsessive-compulsive disorder, even though these are clinical anxiety disorders as well.
At the same time,
the social anxiety behavioral group builds confidence & produces a more rational perception in the persons mind concerning their own abilities & competencies. The behavioral
group must be structured in a step-by-step hierarchical fashion & should include consistent cognitive reminders before
& after people actively work on their specific, individualized anxiety hierarchies.
Thus, the cognitive-behavioral therapy we do for social anxiety doesn't contain the same information or
proceed in the same manner as cognitive-behavioral therapy for other mental health care
problems.
For example, CBT
for depression is very different in nature than CBT for social anxiety. Because the problem is different, CBT for social anxiety contains
different methods & strategies than CBT for depression, panic disorder or generalized anxiety disorder. Thus, cognitive-behavioral therapy, while always being active, structured & solution-focused,
must employ different ways of overcoming the particular emotional problem in question.
CBT isn't a "set
of methods" that work for all disorders. There are not simply 2, 3, or 4 strategies that work to help everyone w/all kinds
of mental health care problems.
Thus, the specifics
or details of CBT aren't universally applicable. This has been a thorny issue for professionals who don't really understand
what cognitive-behavioral therapy involves. With the advent of managed care, the insurance
companies now want therapists who say they can do "cognitive-behavioral" or "solution-focused" therapy.
So, in order to
be included in these groups & panels, professionals now will usually say they do "cognitive-behavioral
therapy".
But what exactly
does this mean?
At this point in time,
almost every licensed therapist knows the accepted terminology. The question becomes do they understand CBT & can they
do it? This is only the first relevant question & the first hurdle to cross.
The second issue
the professional must understand & must be able to accomplish concerns their ability to use specific CBT methods & strategies to help people w/a particular disorder, such as social
anxiety.
When specific cognitive-behavioral therapy for social anxiety isn't understood or put into place, then people
w/social anxiety disorder will not receive the help & assistance they need to overcome this debilitating anxiety disorder.
Because each mental
health care problem is different & because people w/social anxiety disorder respond to different CBT methods, strategies
& approaches, the professional should be cognizant of how to lead, guide & help people w/social anxiety overcome this
specific anxiety disorder.
I receive dozens
of e-mails & other correspondence each day, w/one of the recurring themes being, "I went through
cognitive-behavioral therapy & I didn't get any better. Whats wrong?"
The answer to this
question is another question: "Did you receive appropriate, comprehensive cognitive therapy
& appropriate, comprehensive behavioral therapy & were the cognitive
& the behavioral components of the therapy "reinforced together" in your mind by your therapist?
This, of course,
leads to the question: "What exactly is comprehensive cognitive behavioral therapy &
how does it differ from traditional cognitive behavioral therapy?"
The traditional
answer to "what is cognitive-behavioral therapy" has been "restructuring" the mind (i.e., thought
processes) by means of disputing irrational thoughts & beliefs & substituting rational thoughts & beliefs in their place. There's usually mention of breathing exercises
& relaxation techniques as well.
"Cognitive restructuring"
or "learning to think rationally" are essential components of cognitive therapy for social anxiety disorder. However, while learning to
notice & eradicate automatic negative thinking (& slowly moving the thinking up to automatic rational thinking) is essential for overcoming social anxiety, there are 15 to 20 specific steps that need to be learned to be able to do this.
You can't tell
a person w/social anxiety to simply stop thinking negative thoughts. Obviously, the person doesn't want to think negatively & if they could choose to stop thinking negatively, they'd do so in a heartbeat.
We must employ
very specific ways to allow the person to begin to
-
catch their own automatic negative thinking
-
find distractions to use while therapy is in progress,
-
begin to turn the tables on automatic negative
thinking gradually
The mind will not
accept "irrational positive" statements or beliefs. Repeating "I'll wake up in the morning & be happy, content & less anxious" will do absolutely nothing, because this statement is irrational, given the current state of the mind.
Therefore, emphasizing
positive thinking & giving out positive thinking statements to people w/social anxiety disorder is going to be ineffective
& will only prove to the person that the therapist doesn't understand & doesn't know how to successfully treat social
anxiety.
The mind can't
work overnight & can't be pressured into learning things faster. So, it's important, in the cognitive process, to turn
the tables on automatic negative thinking slowly.
To do this, people
w/social anxiety learn to catch their automatic negative thoughts & then make them rationally neutral. As they find this process easier,
they begin to catch more of their automatic negative thinking. This, in turn, leads to consciously turning this negative thinking
into rational neutral thinking. Then, this neutral thinking is gradually moved up, always in a step-by-step manner, to a more
realistic level, so that w/time & repetition, the persons thinking moves slowly upward & becomes more realistic.
At first, this
is a conscious process, but the more it is practiced & repeated, the more it becomes an automatic process.
Now, to get even
more specific, how do we accomplish these cognitive goals? We use a series of printed handouts that accompany the office
visits. The role of the therapist is to know what to do & at what pace therapy can proceed w/each individual.
People w/social
anxiety need printed handouts that explain, w/specificity:
-
how to stop automatic negative thinking
-
how & why to use distractions
-
how to turn automatic negative thinking neutral
-
the importance of repetition & consistency
in this process
-
how to gradually keep turning the tables on the
automatic negative thinking until it becomes realistic & rational
We use approximately 20
handouts (i.e., printed methods, strategies, concepts & techniques) that guide the person
along the road to rational & realistic thinking in this step-by-step manner.
Even though automatic
negative thinking & feeling are an essential part of cognitive therapy, there are many more facets to this therapy.
If cognitive therapy is seen only as a thinking change process, then this therapy will not
be strong enough, in most cases, to overcome social anxiety.
At this point,
there are many other cognitive issues that must be presented & solved. For example, there are many cognitive methods of
lessening anxiety, especially as it applies to interpersonal relations & groups. These methods must be presented, practiced,
& used to give the person w/social anxiety the feeling, even though it's small at first, that they have some control over
their anxiety, particularly in social situations.
The use of only
one method, such as relaxation, is never enough. Not everyone w/social anxiety can learn to relax enough so that it becomes practical & usable in real-life situations at first. So, it's the therapists responsibility
to have many ways (i.e., methods, techniques, strategies) to allow the person to begin to
control their own emotions.
We have found that
it's important to have the cognitive therapy written out in handout form for the patient. In this manner, they understand
it better, recognize the rationale behind it & then can practice this method or strategy (over
& over again) when they're at home during the week.
At least a dozen
more cognitive problems must be solved besides the two already mentioned. Lack of space prohibits a detailed discussion, but
some of the every day problems that must be worked on & solved if we say we are helping people overcome social anxiety, are the persons:
- misperception of themselves in terms of appearance, ability
& self-worth
- feelings of guilt & embarrassment arising from past social situations
- anger arising from past situations
- self-assertion strategies to show the person they don't
need to be a doormat
- perfectionism & how to become more realistic
- procrastination habits that exist because of social anxiety worries & doubts
In one sense, you
could lump all of these things together as "irrational beliefs," but these problems don't fit neatly into this category, like automatic negative thinking.
Each of these additional
problems must have solutions, too, that are practical & viable in the real world. Thus, from the cognitive
therapy standpoint, the therapist should have the methods & strategies in handout form so that each of the above
mentioned problems may be addressed & solved.
Each handout is
a solution to a particular social anxiety problem. The more areas of social anxiety that are addressed & the more solutions that are found, the quicker, easier & stronger the healing becomes.
Again, I don't
mean to imply that the social anxieties I've mentioned so far are a complete listing. There are many other issues relating to social anxiety that should be resolved. Again, we feel strongly that a written handout w/the problem, the rationale & the solution on
it are essential to adequate progress in this area.
Then, it's up to
patients & their motivation to carry thru with the cognitive therapy. The therapy must be "practiced" at home (when they're alone & not feeling self-conscious) for approximately 30 minutes a day.
Persistency is the next
key. These solutions must be practiced every day for 3 months or longer. It's essential that the brain receive these
new, rational, forward-moving messages so that thinking can be changed (i.e., the neural pathways
in the mind "absorb" the cognitive therapy & it begins to become a part of the person). This constant repetition
of the material that solves the social anxiety puzzle is what allows permanent change to occur in people.
This is just an
introduction to the intricacies of cognitive therapy for social anxiety disorder. But it takes the mastery of these concepts (& many more) before a program for social anxiety can be successful.
Since the term
"cognitive-behavioral therapy" is being thrown about indiscriminately, we feel that the
need to define CBT differently as it's employed for social anxiety. Thus, we're beginning to use the terminology "Comprehensive Cognitive Behavioral Therapy"
to refer to the therapy that's most efficacious for social anxiety disorder.
This also differentiates
social anxiety CBT from the mistaken idea that relaxation strategies, keeping a journal & changing some irrational beliefs is all that it takes to overcome this disorder.
So far, we have
discussed the cognitive component of the therapy.
Behavioral therapy
is also essential for people w/social anxiety disorder. Behavioral therapy, by definition, is active & structured. But heres where the typical
understanding of "behavioral" breaks down, when it's applied to people w/social anxiety disorder disorder.
The behavioral
component of the therapy has typically been explained as "exposure" (i.e., exposing people w/social anxiety to situations which they fear, so that they will habituate, or get used to, the feared situation.)
As you may notice,
this definition has 2 problems. While being fairly accurate, it:
- is too vague & contains no specifics
- doesn't explain or address adequately why "exposure" for social anxiety must be done differently than "exposure" for people w/other mental health care disorders
Most therapists
think of "behavioral therapy" as "exposure" to real-life anxiety-producing situations. Anyone
familiar with social anxiety disorder knows that exposures don't work, they only cause damage, & they keep the person locked in the vicious cycle of anxiety,
irritation, frustration, anger & depression.
People w/social anxiety know why these "exposures" don't work. For example, at the worst stages of my own social anxiety, I was constantly "exposed" to anxiety-producing situations. There were many situations I couldn't avoid. I had no choice.
I had to "expose" myself to these anxiety-producing situations even though I didn't want to do so.
For example, at
one point in my life I was a teacher. I did fine w/students, but when it came to parent-teacher conferences, I'd dread the
experience (the "exposure") weeks & weeks ahead of time. The anticipatory anxiety &
fear was so strong that it gripped at my stomach & made me feel like it was bloody & raw.
Over the course
of 9 years, I was required to go thru 33 weeks of parent-teacher conferences. I was exposed to one of my greatest fears &
the repetition & further exposure to this fear didn't cause me to lose my anxiety & feel more comfortable.
Instead, I
faced my fears & my fears became even stronger.
This is only one
example of why traditional "exposure" techniques are counterproductive for people w/social anxiety disorder.
Equally annoying & discouraging to people w/social anxiety is the oft-mentioned "face your fears" & you'll become anxiety-free. Several books on the market have this terminology
in their title & it isn't only a wrong course of action to take w/social anxiety, it's an action that leads to doubt,
depression, questioning & even more anxiety.
Some of the worst
advice given to people w/social anxiety is to "buck up & face your fears". This will not work. It'll backfire, cause more anxiety & depression & damages lives.
The term "systematic desensitization" is also used as a behavioral technique for social anxiety. This is actually a strategy that will work, given that the therapist knows how to adequately & to appropriately implement
it.
The "systematic"
part of systematic desensitization is highly important. In behavioral therapy for social anxiety, the progress must be systematic, step-by-step, hierarchical & repetitious. If it moves too fast, or if it's too
much, this therapy will backfire. It's very important that any process of desensitization be gradual & systematic.
However, we tend
to shy away from this terminology as well, because:
- not everyone means the same thing when they use it
- it can easily be misunderstood & misused.
Thus, we are more
prone to consider behavioral therapy for social anxiety as a gradual, step-by-step process, one that's never helped by force, pressure, or flooding. We've begun to call these behavioral
activities "experiments" to differentiate them from other behavioral terminology that may be confusing when applied to the treatment of social anxiety disorder.
When we began our
behavioral therapy group in 1995, we held it on a week day evening for 2 hours. As more people w/social anxiety joined the program, we had 2 or 3 evenings a week dedicated to social anxiety behavioral group therapy.
While this schedule
worked, there were several problems w/it, principally tiredness & time. Most people came directly from a full day of work
& were understandably tired. There was also the growing realization that the time allotted (i.e.,
2 hours) wasn't optimal to accomplish all that was needed.
At the beginning
of 1999, we began using Saturday as the cognitive therapy day for new people (mornings)
& the behavioral therapy group for new & returning peopl (afternoons). By taking
this approach, we found we could lengthen the behavioral therapy time by an hour & have a group of people who were more
rested & relaxed, relative to a weeknight group.
Thus, while still
providing individual appointments for cognitive therapy & maintaining an evening behavioral therapy group, we launched
an all-day Saturday CBT group.
In general, we
believe the Saturday approach works better, is easier for patients & most likely shortens therapy. In our initial assessment,
the behavioral therapy group on Saturday afternoon has proven to be a more effective approach to group therapy relative to
a weeknight group.
The behavioral
therapy group must be individualized to allow for each person to work on their own specific anxiety hierarchy. While many
of the behavioral activities will be the same for people w/social anxiety, some of the behavioral experiments necessary will be different from person to person, due to specific fears.
For example, the
vast majority of people w/social anxiety list "presentations/speeches" & "making introductions" as part of their anxiety hierarchy. "Mingling" or making small
talk, especially w/strangers, usually makes the anxiety hierarchy as well. Everyone in the group works on these anxiety problems
& we do most of these activities together.
Other behavioral
experiments that the majority of people practice on in the behavioral therapy group are self-assertive role plays & the
ability to deliberately do something foolish in front of a group of people. However, these behavioral experiments don't fall
on every persons hierarchy. If a person doesn't have anxiety w/these particular social activities, they don't need to be doing
self-assertive role plays &/or foolish things in public.
An experiment that
is essential to some group members, such as learning to look other people directly in the eye, isn't a problem for many other
group members. So, members who need to work on this will use one of our behavioral therapy experiments, such as the Stare
Chair, the Stand Stare, or the No-Personal-Space Stare. While these techniques are very helpful to people w/eye contact anxieties,
many other people don't have this anxiety & therefore, don't need to work on this experiment.
The purpose of
the behavioral group is for everyone to work on their own individualized anxiety hierarchy. The focus is on doing what
is needed for the individual to overcome social anxiety.
We've found that
the best & most permanent results don't occur in the first behavioral group. Thus, we encourage people w/social anxiety
to continue with the behavioral group therapy for as long as it takes to fully eradicate social anxiety.
Most people notice
a large amount of progress after completion of cognitive therapy & the first behavioral group. This, of course, is good,
but people also realize by this time that they can make more progress & conquer more social anxieties. As a result, over 90% of people at The Social Anxiety Institute choose to continue on into a second behavioral therapy group
where they continue to build upon the successes experienced in the first group.
Therapists should
encourage group participation & continuance at this point, because even the most motivated of people can't get to the place
where they want to be (i.e., relatively free of anxiety) w/just one behavioral group under
their belt.
The persistence
& consistency in the behavioral group program pays off well & the improvement over anxiety is even clearer as time
progresses. I should mention that our therapy costs are low, relative to other programs, we use sliding fee scales & when
people choose to continue group behavioral therapy, the cost is more than cut in half, thus
allowing everyone access to continue w/therapy, regardless of financial situation.
As a result of
our "intensive" CBT sessions in which people from all over the world come for comprehensive CBT, we found that therapy was
more effective if we took what we were learning & applying in the therapy group out into the real world.
So, beginning in
1998, we formally added these outside-of-the-clinic "experiments" to our comprehensive cognitive-behavioral
therapy program. For example, when the group is ready for this, we go to a local shopping mall, a university campus,
or a downtown area in which we know there will be people milling around. Then, depending on the individuals anxiety hierarchy,
the "experiments" that are available to us in our progress against social anxiety are numerous.
When the group
goes to a shopping mall, i.e., one of the activities we use to decrease self-consciousness & become more comfortable w/being
the center of attention, is finding a table at the malls food court, ordering some food or drinks & staking out a table.
Then, one of the members goes & gets a bagel or muffin & we put a candle in it, light it & sing happy birthday
to the group member who has chosen to do this "experiment".
Before
every experiment we talk about it from a cognitive perspective & each person who participates in an "experiment" has volunteered
to do it because they know it will help them overcome their social anxiety. The birthday party experiment in public places is effective because the birthday person is asked to slowly look around the
mall at other people while the birthday song is being sung to them & while they are the center of attention.
They'e generally
surprised that peoples reaction is either positive (i.e., many people smile at us & some even sing along) or neutral (i.e., many people simply ignore us). We have performed this particular experiment over a hundred times now,
w/no adverse response.
Space again doesn't
allow us to discuss each & every behavioral technique we use in the real-world "experiments." Some of the other outside-the-clinic
experiments we've found helpful include initiating conversations with salespeople, going "up" the down escalator, skipping
thru the mall like schoolchildren, yelling at each other to "wait up for me" in a crowd & talking to strangers in stores
concerning a product or an item that they are looking at (e.g., "That looks like an interesting
book. Does it seem to be pretty thorough?")
The opportunities
for outside-the-clinic experiments are too numerous to list. We've found that having the entire group there, plus an anxiety
mentor, ensures that everything goes smoothly.
We work out everything
first, before we leave the clinic. That is, people know what experiment would help them w/social anxiety & they know how much they can do at any given time. We work w/people to ensure that their choices are reasonable, hierarchical
& are proceeding in a rational way.
In addition, a
pre-experiment rationalization is given (i.e., what to look for & expect during the experiment)
& a post-experiment rationalization (i.e., a debriefing) is provided to ensure that
the person interpreted the experiment correctly & was thinking along rational lines.
So, for the above
reasons we're beginning to use the term "comprehensive cognitive-behavioral therapy." It's important that professionals
& people w/social anxiety disorder understand that treatment for social anxiety must be thorough & comprehensive.
Using only
a few methods, concepts, statements & techniques will prove unsuccessful.
Cognitive therapy
alone, while helpful, will not provide adequate relief from social anxiety. Behavioral therapy alone doesn't allow the brain to change its perceptions & beliefs unless a feared activity is done hierarchically & successfully & then cognitively reinforced. It's important to integrate the cognitive
& the behavioral therapy, although this doesn't need to occur at the same time.
Comprehensive cognitive-behavioral therapy implies that we will use every method, strategy & concept
useful to us. We'll provide many options to reach the goal & not be dependent on one cognitive strategy to work miracles.
We must use all
the cognitive strategies at our disposal, reinforce the necessity of persistency & consistency in social anxiety therapy, & make available any form of behavioral activity or experiment that will help the person slowly move up their
anxiety hierarchy in the behavioral group.
As w/the cognitive therapy, the behavioral activities or experiments must be thorough & comprehensive.
The therapist should have a list of several dozen behavioral activities that should give the person w/social anxiety more peace & confidence as they work on these activities as the group progresses.
For the successful
treatment of social anxiety, both the cognitive & behavioral therapy must be thorough & comprehensive. Reinforcement must be continuous &
the person must be motivated to stick to a 30 minute a day practice routine.
This course
of action isn't the path of least resistance for either the therapist or the patient. However,
it's the best way we know to overcome social anxiety disorder. Most people w/social anxiety will tell you that, even though they can see there's much work ahead, they're willing & motivated to do it, because the work is nothing in comparison to the daily nightmare of living w/social anxiety.
This hope, progress
& eventual success is what keeps all of us in a positive frame of mind & moving forward to our ultimate goal.
Thanks to Michael J. Lee for his assistance in clarifying
the CCBT behavioral program & outside-SAI experiments.
What is
Cognitive-Perceptual Theory?
by Arnold
R. Bruhn PhD
"O.k., I've had a crummy life. That make you happy? But I don't want
to waste the time I have left by dwelling on all the crap that happened to me when I was a kid. It was bad enough having to
live thru it the first time."
I'm not sure how many times I've heard this, or something
like it, in my career as a therapist, but I wish I had a dollar for every time a client
told me that.
There's just one problem. Much as we might like to wipe the slate clean
when the clutter in our memories becomes a pain, that isn't an option.
You lived it? You deal with it. Like it or not. Even when it's not your fault. Our experiences are the raw material
we use to construct our sense of self, others & world. Whether we want it to or not, the mind takes the raw material of experience & does something with
it.
Cognitive-Perceptual theory is designed to help us understand the sense that we've made of our life experiences.
Figure it like this. Say you
move from one house to another. What happens? You pack up your belongings, right & take them along. At least the most
important ones. Autobiographical memory does the same thing - it saves our most memorable & useful experiences. And we
pack these along with us, no matter where we go.
Cognitive-Perceptual (CP) theory
is a theory of personality designed to explore the interrelationship between autobiographical memory & personality.
Autobiographical memories of interest to CP theory involve those for specific events which have the form, "I
remember one time...."
Traditional memory researchers who seek to understand how memory operates want to minimize or eliminate the influence of personality.
When personality affects memory functioning, these scientists perceive this as "white noise", or error variance,
that interferes with what they want to observe.
Research designs seek to minimize the effect of this kind of white noise. This orientation also holds for traditional
autobiographical memory researchers in the case of certain autobiographical memory products - i.e., memories of widely known
events such as the Challenger disaster or President Kennedy's assassination - because they're almost universally remembered
in certain population groups & the objective facts (date, place, events in question)
are widely known.
Thus, traditional memory researchers & CP researchers are often both interested in autobiographical memories,
but from opposite perspectives - CP researchers want to better understand how personality manifests in memories & maximize these influences, whereas traditional memory researchers want to minimize
any effects of personality.
The CP theorist seeks out exactly the kind of information
that traditional memory research avoids. The CP theorist wants to maximize the role of personality in memory functioning & come to know it for what it is.
For we understand that memory, however it's conceptualized, isn't like an operating camera or a computer hard drive.
Memory tends to operate in a highly individualistic manner; perception is similarly quirky.
Some people have excellent memories, some poor. Some are visually oriented in their recollecting, others auditory.
Some are oriented toward the large picture, others toward details. And differences in initial perceptions are similarly known,
which are well documented in the eye witness literature (See Elizabeth Loftus' important research
for examples).
The CP theorist is specifically interested in understanding how it is that people have such different recollections of their lives, even individuals who have grown up in the same family.
How can we account for those differences?
CP theory is concerned with memory differences
that involve personality, as opposed to biology. i.e., attention deficit disorder in most cases likely originates with neurological
deficits or quirks, allergic problems & other biological variables that cause problems with attending although there are
also some instances in which emotional problems can cause attentional difficulties.
In the most general sense, CP practitioners are interested in what kinds of personality variables bear on the
process of recollection.
Based upon 25 years of research & observation, we propose
that those aspects of personality which impact autobiographical memory the most involve important interests, high priority
needs, major attitudes & key unresolved issues.
Although a full explanation is beyond the scope of this presentation, we can at least outline how personality
becomes intertwined with perception & memory. Those who want more information are directed to Bruhn 1990 a, Bruhn 1990
b (see References)
Personal memories tell
us about what kinds of events are important to an individul, how these events are commonly constructed & generally how
the person interacts with other people & the world about him.
Just as important, memories reveal expectations about these key events, which are imbedded in the very structure of the recollection.
These expectations in turn influence perceptions of similar events that occur in the present. While there exists an objective reality
separate & apart from us, we apprehend that reality in an idiosyncratic manner, consistent with our past experience of that reality.
Similarly, individuals from a common culture tend to maintain elements of a common cultural world view. When
individuals from opposing warring cultures interpret the actions of an enemy, they look at the same incidents from such radically
different perspectives that an impartial observer may have trouble recognizing the same incident.
The belief system which we maintain as individuals has its parallel us to the cultural views which we just noted in the sense that each
of us constitutes in a sense our own unique culture.
When we consider autobiographical
memories from the perspective of personality, certain central questions must be addressed. The following, which are among
the more important, informally stake out the domain of CP theory:
- How can I understand how lifetime memories are selected - i.e., what causes me to recall ‘X', as opposed to ‘Y'?
- What causes me to remember what I do in the way that I do?
- What helps me to understand the relative persistence of certain memories thru long periods in my life?
If you, also, wonder about
such matters, you've now entered that murky no man's land of not necessarily fact & not necessarily fiction, a.k.a., memory
garnished liberally with personality.
Your next step is to venture
to my web site. There you'll find the answers to these & other questions
& some procedures (Online Book Store) that will enable you to access memories that can expedite your own personal journey
of self understanding.
What are talking treatments?
Talking treatments or psychological
therapies involve the person w/a mental health problem talking about his or her problems, usually to a trained listener. Talking treatments often take place alongside other treatments, for example medication.
Talking treatments seem to
be more effective in treating some mental health problems than others, i.e., depression, anxiety & stress disorders. They also seem to be most effective when the person doing the talking & the person doing the listening establish a good relationship w/each other.
If you're the person doing
the talking your own attitude is also important. If you're determined to make it work & you're completely honest w/yourself the treatment is more likely to work.
Some talking treatments, such
as counseling, may be offered thru a variety of agencies. Other talking treatments are usually only offered by appropriate professionals, for example psychodynamic
psychotherapy is usually only offered by psychotherapists.
EMDR - another
treatment method in counseling
In the last several years
a technique called Eye Movement Desensitization & Reprocessing (EMDR)
has been turning heads in the field as a way of "digesting" the disturbing emotions & processing the memories.
The technique was first
developed by the clinical psychologist Francine Shapiro, Ph.D., who noticed that whenever a disturbing thought entered her mind, her eyes would move back & forth.
This movement seemed to
shift the disturbing thought from her consciousness & when she brought the thought back to mind again, it wasn't as bothersome.
Dr. Shapiro then began testing
her theories on survivors of combat & sexual abuse, with positive results. Recently, the efficacy of the treatment has been supported by a number of controlled studies. About
22,000 practitioners offer it nationwide - from private offices to emergency shelters.
When using EMDR, a therapist typically asks the patient to bring to mind an image of the traumatic memory & to experience
the negative emotions that go w/it. While doing so, the patient moves his or her eyes quickly back & forth following the therapist's hand.
This is the desensitization phase.
No one is quite sure how
EMDR works, however. Even Dr. Shapiro, who coauthored "EMDR: The Breakthrough Therapy for Overcoming Anxiety, Stress and Trauma"
(Basic Books, 1997), can only speculate.
One theory asserts that
traumatic events differ from normal events in the way the brain processes them. What the eye movement appears to do is facilitate
desensitization to the painful memory, helping the brain "digest" the event.
EMDR can be an incredibly
emotional process & should be done only w/a qualified practitioner. I have no direct experience with the practice, but
it looks like a nonharmful, noninvasive method that may work & is definitely worth trying.
For a referral to a certified
practitioner, contact the EMDR Institute, PO Box 51010, Pacific Grove, CA, 93950 or call (408) 372-3900.
Treating Adolescent Survivors of Sexual Abuse
Child sexual abuse; it isn't a topic that makes people comfortable. Discussing child sexual abuse, in fact, remains taboo even in this era of
increasing openness about personal or family difficulties. While most Americans can understand, although not condone, how
some forms of child abuse occur, it's almost impossible for them to consider the idea of sexual abuse. This is particularly true when the abuser is a parent or family member.
Sexual abuse fuses those areas in which most people still experience discomfort: sexuality, power, gender domination & the horrific
exploitation of an innocent child. Sexual molestation, like so many forms of abuse, wounds not only its victim: it cuts thru
families and communities, destroying trust & the belief that some things simply don't happen in an enlightened society.
And yet they do. Almost 1
million children were identified as victims of substantiated or indicated abuse or neglect in 1996, according to the Office
of Child Abuse and Neglect (formerly the National Center on Child Abuse & Neglect),
U.S. Dept. of Health & Human Services (DHHS). About 12%
of these children were sexual abused. The figures, of course, include only those incidents of abuse that were reported to & investigated by, child protection
agencies.
Despite these numbers, the
Nation lives in denial. The results of this country's refusal to confront the sexual molestation of children are staggering.
These include gaps in services to young survivors, little research into the effects of sexual abuse, inadequate technical assistance on effective approaches to supporting youth who have been sexually abused or intervening with their families & few therapists trained to provide appropriate services.
The limited intervention &
support typically given to youth survivors is compounded by the fact that they must deal with their trauma in a society that
is reluctant to acknowledge that child sexual abuse even occurs.
Denial is a costly tactic:
- The research shows that victims often become victimizers.
- Victims seek comfort in behaviors, such as alcohol or drug
abuse, that have consequences for the larger community.
- Severely wounded children sometimes grow up to be violently
aggressive adults.
Moreover, a Nation is judged
by how it cares for its most vulnerable populations, and to ignore the victimization of children is unacceptable.
Talking About the Unthinkable
20 years ago, no one wanted
to admit that men beat their wives. Domestic violence was unthinkable, especially in affluent neighborhoods. Today, people
know that domestic violence occurs in families across the spectrum of racial groups & education & income levels. Society's
perception of & response to, domestic violence was changed by battered women's advocates who continued to talk about violence
in the home, even when those around them wished they would stop.
Today, that education process
must continue. Violence in the home includes sexual violence. And just as with domestic violence, the effects are intergenerational.
Clearly, preventing the sexual
abuse of future generations by treating the victims of today should be a priority. A key strategy for doing so is to implement
a youth development approach that ensures services & opportunities for all youth, that builds on young people's strengths
& that provides support for youth whose developmental process has been delayed by abuse & neglect.
Young people who have been
sexually abused, especially by a trusted adult, suffer damage to almost every aspect of their personal development: sexual,
physical, emotional & spiritual.
Our culture demands that children
mature from an egocentric to a sociocentric focus. They're expected to participate in school, become involved in the community & develop relationships outside their families.
This is a challenging process even for the average young person; living with abuse makes the process incredibly difficult. During adolescence, youth are growing & changing in a range of ways that are affected by sexual abuse:
- Physiological
Change: How tall they are or how much they weigh becomes a source of concern to young people during adolescence, particularly as they compare themselves with their peers. That comparison may produce
feelings of anxiety or contribute to dampening their self-esteem. For youth who have experienced abuse or criticism by their parents, teasing about their looks may reinforce their perception that they're not valued.
- Emotional Development:
Young people in abusive situations must redirect their energy from emotional development to survival. When they're forced to focus on avoiding the violent or sexual advances of an adult caretaker, they don't make the same developmental progress as children who receive
unconditional love, support & guidance.
- Cognitive Change:
Young people develop their cognitive thinking ability, which means that they will reexperience & reframe abuse that occurred to them earlier, particularly if it began when they were young.
- Moral & Spiritual
Development: During adolescence, youth begin to question the meaning of life & specifically to think about
the larger world, the role they play in it & the options & opportunities available to them.
- Sexual Development:
For some young people, it's during adolescence that the real consequences of being sexually abused occur. When a child of 3 or 4 years of age is sexually abused, it isn't a sexual event in the way adults may think.
It's physically
hurtful, confusing & alarming, but they don't have a context for defining the abuse. When those children turn 12 or 13, they cognitively reassess the abuse as they begin to learn about or experience sexual feelings.
While all young people's development
is affected by both internal & external factors, each youth experiences growing up differently. For youth who are abused, however, that process is negatively affected, resulting in certain reactions or behaviors.
While there's no clear profile
of a sexually abused child, the research indicates that there are symptoms that present frequently in young survivors.
These include the following:
These youth are
hyper-vigilant, scanning the environment for threats to their safety; conversely they've learned to shut down their feelings.
The chronic timing of the abuse plays a part in the level of anxiety experienced by child victims. Youth who've been assaulted through most of their developmental phases have learned to maintain
a defensive posture to protect themselves.
They've learned
the most debilitating lesson of child abuse: people who love you hurt you. For these children, the expression of caring is presumed to be followed by harm or danger.
At the end of 4 months of therapy, 6-year-old "Katie," i.e., brought a paddle to her therapist. When
the therapist asked about the paddle, Katie said,
"It's for you to hit
me with." When the therapist asked why Katie thought she wanted to hit her, the child
replied,
"Well
you like me, don't you?"
The sad reality is that children seek out behaviors with which they're familiar. In some instances, children do so to master or take control of situations, thereby reducing their anxiety about what might happen next.
They flinch at
sudden noises (startle easily) & are hyper aroused or overstimulated
easily.
They may experience
acute fear in some situations & typically "stay on alert," which requires energy & takes a tremendous toll on their physical
& mental well-being.
They tend
to carry a lot of tension in their bodies, so they may not move as fluidly as other children. Many of these youth present
somatic concerns, such as always having headaches or stomach pains.
Again, the chronic
timing of the abuse is an important factor in the degree to which young people develop hypersensitivity. If the abuse is an isolated incident, the child is better able to regroup.
When the assault is frequent
or long term, the child doesn't have respite to reorganize or stabilize & must develop highly refined defense mechanisms.
She asked what
he expected to see & he replied, "guck." Through further questioning, the therapist learned that
the boy expected guck to come out of his arm like the bionic man on television.
This boy thought of himself as a robot, which is a strong defense mechanism against being hurt. When he saw the blood, he actually felt better because he could say, "I'm a real human being." For the next 3 weeks, he'd be more interactive, responsive & happy because he had verified his own existence.
- Alcohol or Drug Use: While some young people may experiment with drugs or alcohol as a rite of passage, youth who were or are abused use substances to numb their feelings.
The alcoholism of one 6-year-old child was discovered when her preschool reported unusual behaviors to her foster family. The child was
given a medical examination, through which the doctors determined that she'd been sexually abused.
She was referred to a therapist who used play therapy. The child would pick the play therapy rag
doll up & roll its head back & forth, put one foot in front of the other, as if the doll were walking & then make
it fall. She repeated the sequence 14 times.
After watching this behavior, the therapist wondered if the child was acting out the behavior of someone who'd been drinking. The
therapist brought in a small bottle of liquor, the type you get on an airplane & waved the open bottle under the child's
nose, asking if she had ever smelled the odor before.
The child grabbed
the bottle & tried to drink its contents. Through further questioning, the therapist
learned that the child kept a bottle of vodka she had smuggled from her home to the foster residence inside the zipper pouch
of a stuffed animal.
It turned out
that the child's father had given her alcohol in a bottle so that she would relax & go to sleep while he sexually molested her. The child learned that when she drank, she could go to sleep & have the experience of not being "present" while the abuse occurred.
- Problem Sexual Behaviors:
Children who were sexually abused may become involved in sexual acting-out behaviors, particularly when they reach adolescence, a time of increasing biological
urges & exposure to sexual education.
Under normal conditions,
sexual behavior develops gradually over time, with youth showing curiosity & then experimenting with themselves & others.
When
children are sexually abused, however, they're prematurely exposed to material they don't understand & can't make sense of.
Moreover, children become conditioned to respond to certain
things. In many instances, adults who interact sexually with children may reward them before or after the event. The children
are conditioned to believe that if they engage in certain behaviors they'll be rewarded. This is pure learning theory: children repeat acts for which
they receive positive reinforcement.
A judge who was doubting the sexual abuse of a 3-year-old child called everyone into his chambers & hoisted the young girl on his lap so that he could interview
her.
-
The moment he placed
her on his lap, she reached under his robe & began fondling his genitals. She clearly had been conditioned to believe that when a man sits her on his lap, he expects this type of behavior. The judge quickly reversed his opinion & went forward with the case of sexual abuse.
Some children who were sexually abused also may become sexually provocative, dressing & talking in a manner that puts them at risk of further sexual exploitation. Others merge sexual behavior & aggression & become the victimizers of other children.
-
Aggression: Eventually, most abused children get angry & some begin to act aggressively, typically with smaller children. This is the victim-victimizer dynamic; abused children learn that the bigger, stronger person hurts or takes advantage of the smaller, weaker person.
Youth who've been
victimized are conditioned to believe that when 2 people interact, one of them will be hurt. At each interaction with others, they may wonder who will be hurt this time.
Some children adopt
the victim role; others become the victimizers. In either case, they simply are playing out the roles that they've been conditioned
to believe people play during interactions with others.
The research would indicate that boys
tend to adopt the role of aggressor more often than girls. They have a harder time tolerating the role of victim, which is in stark contrast to the cultural
definition of masculinity.
Girls tend to
adopt the role of victim more often, which could be linked to the traditional social view of women as the weaker gender. Yet neither pattern holds
true in all cases. Some boys take on the victim role; some girls become aggressive.
Obviously, these behaviors
& reactions are learned. Young people who have survived sexual abuse can just as easily learn more positive behaviors if communities choose to provide them with appropriate interventions & support.
They need support in both working through the trauma & addressing the developmental stages they may have missed because of the abuse. This includes the critical step of developing an identity separate from their family or caretaker.
Identity Formation in Adolescence
Forming
an identity is a major developmental issue during adolescence.
This process of individuation,
however, is one that begins when children are very young & crystallizes in adolescence. For positive identity formation to occur in any human being, some basic things have to be attained, including the following:
- Expressions of
Love: Children have to feel that somebody cares about them.
- Feelings of Significance: Children must feel that they're significant or important to someone.
- A Sense of Virtue:
Children must have a belief in their innate, inner goodness.
- A Sense of Belonging:
Children must feel connected to a family that provides them with a sense of stable belonging.
- Mastery &
Control: Children must experience feelings of mastery & personal power & control.
All of these variables are
severely compromised by child abuse & neglect. Abused children's sense of self & their future has been badly damaged.
They may have learned that
negative attention is better than no attention & they act accordingly. Unfortunately, their behaviors, which result directly from
the abuse, often lead significant people in their lives to react in ways that reinforce this negative self-image. This further damages young people's sense of virtue &
feeling of being loved.
To deal with these overwhelmingly negative feelings, some children develop an affect disorder, which results from a person compartmentalizing information about an abusive event separately from their feelings.
They'll describe an abusive event in great detail without emotion, as if it were happening to someone else. This dissociation is a defense mechanism that helps people block reality, especially when it's painful.
Children who are being sexually abused use dissociation to separate from their own experiences. They talk about floating above their bodies or sitting on top of a lamp watching
what happened.
This process enables a young
person not to feel the pain associated with actually being present during the abusive event. Unfortunately, dissociation also creates a problem with a child's sense of identity & interrupts their sense of being anchored in reality.
Children who have an identity
problem or no sense of who they are may, i.e., develop an insecure attachment disorder. Therapists experience this with young people who ask to see them every day or to come
live with them.
These young people don't feel
real unless they're in another person's presence. Or they fear that the person they are with now will go away & not come back, leading to feelings of abandonment & despair.
When children aren't allowed
to develop an identity, they may appear as if they're presenting a "false self." These youth simply may not have a good sense of self to present to the world.
When with other groups of
people, especially other youth with strong personalities, abused children may easily retreat into themselves or mimic those they're around.
Helping young people go back
thru the developmental stages & rebuild a sense of self is critical to their overall emotional well-being.
Therapists have identified 3 stages to working with survivors of childhood abuse:
- establishing the young person's safety, both in their home situation & with the therapist
- processing traumatic material
- fostering social reconnection
One of a therapist's most important tasks is to ensure that a child is living in a safe environment with a central, supportive, caring adult.
Often, young people who've been abused or neglected experience incredible mobility in their lives as they move from one placement to the next. These youth begin to doubt that any adult will be with them for very long. A sense of security & safety in one place, therefore, is very important to the therapeutic process.
Once the child is in a safe environment, the therapist can begin to develop a relationship with the child. Thru that
relationship, the therapist can begin to help the child understand why it's important to process what happened to them.
Most abused adolescents want a sense of control over their lives. Therapists can show youth how, by working thru their earlier experience,
they can eliminate some of their negative feelings & the resulting behaviors. Thru that process, youth can develop a sense of control over their behavior.
When a young person is ready,
the therapist can help them begin affiliating with others & developing the ability to
trust & have relationships with other people, both adults & peers. Often at this stage, a therapist
will place a youth in group therapy.
Time & consistency of care are key factors in all 3 stages of therapy, but especially in stage 1.
By the time an adolescent
receives the help they deserve, they may have been sexually or otherwise abused over a period of time. They have built up an array of defenses to protect themselves & making contact with them may be difficult. To establish the trust of an abused child, a therapist needs to build a relationship with that child, which takes time.
Therapists
need that time to demonstrate that they're trustworthy, by action as well as words.
In some communities, the new managed care systems are threatening this process by covering the costs of only short-term therapy.
The trust of a severely abused child simply can't be established in 6 to 8 sessions. Under those circumstances, experts caution that therapists should work only on phase 1, or the establishment of the child's safety.
It's inappropriate to encourage a child to talk about traumatic abuse if that child isn't in a position to receive ongoing therapeutic support.
In such situations, a therapist must simply advocate for children's safe placement & help them to develop coping strategies, teach them about available resources & suggest behavioral alternatives that may positively affect their interactions with others.
A
therapist also might help children understand that their behavioral problems may be related to something they learned or experienced a long time ago.
Helping youth explore past
abuse is specialized work, requiring significant education, training and expertise. The following key principles provide guidance
for those working with youth who've been sexually abused:
- Remain Neutral
In Your Early Interactions With Abused Children: When some youth sense that a therapist or other professional is paying attention
to or trying to help them, they may withdraw because the circumstances feel risky to them.
The very nature
of counseling or therapy, which involves personal contact
with another human being and focused, positive attention, can produce stress and anxiety for children who've been sexually abused.
Youth who've been
sexually abused also may associate nice behavior with seduction. In the past, people were nice to them when they wanted something. They may
wonder what therapists or other adults expect from them in return for their help.
- Assist Youth In
Understanding That They Aren't To Blame: Typically, left to their own resources, children make incorrect assumptions about why they were
abused or neglected.
When 100 youth in San Francisco were asked why they were in the foster care system, 98 of them said, "Because I'm bad." And young people's behavior often reflects how they
feel about themselves. If they think they're bad, they may act in ways that perpetuate that image.
- Be Nonjudgmental:
Youth don't respond well to adults who want to tell them what to do or who are constantly critical.
- Catch Youth Doing
Something Good: Focus on telling young people what they're doing that's good. When they make a thoughtful decision and stick to it, i.e., congratulate them on following through.
- Help Them View
Their Feelings Without Judgment: Feelings aren't good or bad, they're just feelings. Help young people understand that it's all right to feel angry and help them to learn to express their anger in ways that are healthy for themselves and others.
- Think Of Your Interactions With Youth As "Invitations" For Them To Do Or Say As Much Or As Little As They Choose: Youth need to learn to make choices about how they will participate, or not, in different situations. Offering youth options gives them
a chance to practice making choices in a safe environment.
If a young person
doesn't complete an assignment, i.e., consider talking with him or her about what the assignment might have looked like if
they'd finished it.
Or, discuss what
might have been the biggest problem in completing the task. Through this process, you might accomplish more than if you focus on the young person's failure to complete the task.
- Avoid Power Struggles With Young People: It generally is nonproductive to spend time arguing a point
with an adolescent. Move on to other discussions that might prove more useful. Keep in mind that if a young person is feeling defensive, they aren't feeling safe.
- Remember That
Abused Adolescents Have A Reason To Be Defensive: If you're hit enough, emotionally or physically, you learn to stand ready to protect yourself or even to ward off attacks by attacking first. Young people who've been abused need time and a trusted relationship to feel safe.
- Understand How Easy It Is For Abused Children To Be Further Victimized: Without question, once abused, children become more vulnerable to further victimization. It isn't just the abuse that leaves them exposed to exploitation; it's the concomitant loss of love, nurturing and feelings of being safe and valued. Often adult predators provide, at least at first, the very things missing from an abused child's history: time, attention, caring and a sense of belonging.
- Be Aware That Some Behaviors Provide Youth With A Sense Of Control: When children are treated well, nurtured, loved and accepted, they learn to expect that treatment from others.
When children
are abused, they similarly expect others will abuse them. These children may engage in aggressive behavior as a defense mechanism; their behavior is a means of taking control of a situation they anticipate will occur anyway. When you work with youth to stop behaviors that place them at risk, it's important to be aware that those behaviors may be the only current means they have for mastery and control.
- Help Educate Others
That Young People Are Never Responsible For Their Abuse: Often, people suggest that adolescents should have told someone or fought
back. The expectation is that adolescents should be able to protect themselves.
It's important to remember that many young people have long histories of abuse, which makes them vulnerable; they aren't "normal" (nonabused) adolescents suddenly confronted with
dangerous circumstances.
Moreover, it's critical to remember that children are relating to their parents, the people they love and need most in the world. When asked, "Who is bad, you or your Mom and Dad?" children will always choose themselves. Children need to protect the idealized image of their parents; those are the people they long for.
Working with youth who've
been sexually abused obviously requires special skills and expertise. For that reason, most youth agencies develop strong working relationships with therapists who are experienced
in working with youth who've been sexually abused.
In selecting
a therapist, youth agencies should look for well-trained professionals who understand and apply the above-mentioned principles. They also should look for therapists who
do the following:
- Use Therapeutic
Approaches Other Than Talk Therapy: Direct talk therapy generally isn't the most
effective approach with adolescents. Well-trained therapists will use art or
play therapy in working with abused youth.
They also might
discuss news clippings or watch a video & let youth comment on another young person's situation. It may be easier for
youth to talk about another person as a means of sharing how they feel.
Moreover, helping young people develop empathy for others often can be the first step in developing self-empathy.
- Help Youth Change Behaviors That Cause Negative Reactions In Others: Therapists examine a child's behavior,
describe it & then try to determine why the child is acting in this manner.
A 12-year-old
girl, i.e., who threw temper tantrums explained that she felt quiet inside when the tantrum was over. She said she felt calm because "everything inside had come out." This child had been beaten whenever she showed any emotion, so she had learned to keep her feelings bottled up inside.
Every now and then, however, she had to let those feelings go. Until she entered therapy, the child had never been taught how to live with & manage
real feelings; the result was tension, control and then loss of control.
Her therapist
worked with her, using a tea kettle as a metaphor. They jointly developed a plan for the young woman to begin to let her "steam" out in ways that wouldn't cause concern among the people around her or allow the kettle to "blow its lid."
Through the process,
the young girl learned affect tolerance: the ability to feel, absorb and express her feelings appropriately.
- Appreciate That Children Sustain Injuries Differently: Some young people are more resilient than others.
A therapist needs to assess how well the young person has survived the abuse, what they think about themselves & how they manage to reach out to others. Thru this process, it's important to help the youth build a history of accomplishment by emphasizing the young person's strengths and successes.
- Help Youth Process
Traumatic Material: Young people need support to deal with what happened to them, discharge their feelings and develop a sense of mastery about that process.
Unless this happens,
images similar to those associated with the abusive event may trigger a posttraumatic stress reaction. A youth may blow up or go into trancelike behavior for no apparent reason. This is an indication that they have unresolved traumatic material and they need help in processing that material in a structured way that creates feelings of empowerment.
- Work With Youth
To Assimilate The Information & Feelings Associated With Their Prior Abuse: By processing traumatic material, therapists can help youth talk about the event and feel the associated feelings at the same time.
- Recognize That While Abuse & Neglect Have The Potential To Be Traumatic, Not Every Abused Child Is Traumatized: Traumatized children are a subset of abused children. Factors that distinguish the 2 groups tend to include the child's relationship to the abuser, age at the onset of abuse and biology and the chronicity and severity of the abuse. All abused children are hurt and exploited, but, depending on a broad set of variables, some children continue to live in the climate of the trauma.
- Help Youth Learn
How To Manage Their Feelings In Settings In Which It Wouldn't Be Appropriate To Act Upon Them: Some youth
need to learn affect regulation, which is the ability to control feelings in certain situations. Adults, i.e., who had a fight with a spouse prior to making a presentation at work are able to refocus
themselves. They're able to control the feelings they're experiencing as a result of the fight while they make the presentation.
- Work With Youth
To Develop Impulse Control: Children growing up with abusive parents didn't have impulse control modeled for them. Many abusive parents think and act at the same time; when they're angry, they strike their children.
Nonabusive parents
also get angry at their children; they simply have the impulse control not to act on every thought. Children who grew up with abusive parents may need to learn that thoughts and action can be distant on the time spectrum.
They need help in determining how to go thru a series of steps to make decisions about what they'll do in response to their thoughts.
- Accept That All Children Are Different: Some children act out in ways that continue the climate of trauma thru behavioral reenactments that keep the victim dynamic present in their life.
Others want to
talk constantly about the abuse and will do so even with strangers. Still other youth refuse to talk about the abuse; they say it's over and they don't want to deal with it.
A good therapist will develop a plan for working with a young person on the basis of that child's behavior, presenting problems, personality and coping style.
Selecting a Therapist
Selecting and developing a
relationship with a therapist to whom to refer young survivors is a critical job for youth
service agency staff. The following steps can help youth agency staff choose the right therapist for youth who've been sexually abused:
- Talk with referral sources,
especially law enforcement or child protective services personnel, to find out about local therapists, their approach to working
with youth and their track record in helping young people who've been abused.
- Check with other youth agencies
who've worked with therapists.
- Call the American Professional
Society on the Abuse of Children for referral to the organization's local chapter, which can identify therapists in your area.
- Ask for referrals from the
local chapter of an association of mental health professionals (i.e.,
the American Psychiatric Association or the American Psychological Association).
Interview the therapist, asking the
following questions:
- What type of training and
experience have you had in working with abused adolescents (general & child sexually abuse specific)?
- What type of theoretical
model do you use?
- How do you translate that
model into practice? (Ask them to give examples or role-play what they'd do with a client, such
as how they'd use their approach with an abused child who is acting out sexually.)
- How does sexual abuse affect the adolescent development process and what techniques will you use to help youth process through the developmental
stages impacted by that abuse?
- Do you think there are special issues for youth who've been sexually abused and if so, what are they?
- What local resources are
available in this community for youth who have been sexually abused? (If they're involved in the local community, they should be able to tell you about the local
crisis line/center, runaway shelter, therapists' association & other services.)
- Who are the key researchers,
writers and organizations working on the issue of sexual abuse? (This question will help you determine whether they maintain professional affiliations through
which they stay informed about new research findings or therapeutic approaches.)
- How will you work with agency
staff to ensure the ongoing safety and emotional well-being of young people in therapy? How will you deal with issues of confidentiality while providing agency
staff with the information they need to support youth while they're in therapy?
- How will you work with an
abused child who's going to return to living with the abuser?
- How will you involve other
family members in the therapeutic process while protecting the child from the abuser?
- What approach will you use
in working with a child who is receiving only short-term therapy under a managed care system?
- How will you coordinate the
therapy with other agencies that are providing services to the child?
- May we call, as references,
agencies that have referred young sexual abuse survivors to you?
Once youth agencies have narrowed
the field of candidate therapists through the initial screening and interview process, administrators might invite the top
candidates to conduct a presentation to agency staff on working with abused children.
They can use the time to observe
the therapist's knowledge, style and willingness to discuss issues &/or differences of opinion with agency staff.
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additional resources...
counseling and treatment of mental disorders
terms to get familiar with
abusive behavior observation checklist: A means of assessing the extent or threat of domestic violence
acute stress disorder/acute stress reaction: A DSM-IV classification for a condition where symptoms are similar to PTSD but for where the disturbance lasts for a minimum of 2 days and a maximum of 4 weeks and occurs within 4 weeks of the traumatic event.
acupuncture: A method of encouraging the body to promote natural healing and to improve function by inserting needles and applying heat or electrical stimulation
at very precise points.
affective disorder: A disorder of mood (feeling, emotion). Refers to a disturbance of mood and other symptoms that occur together for a minimal
duration of time and aren't due to other physical or mental illness.
agoraphobia: Often described as a fear of open spaces but it's actually more to do with a fear of places from where it's difficult to escape, such as crowded shops or buses. It's also linked to a fear that you might embarrass yourself, i.e., by fainting.
antisocial personality: A personality style beginning in childhood that involves a behavior pattern that seriously violates the rights of others. Individuals with this disorder are irresponsible in their work, school, finances and personal relationships.
apathy: A symptom of several mental illnesses, apathy is a lack of emotion or interest in things one would ordinarily consider important.
aromatherapy: The basic principle of aromatherapy involves
inhaling therapeutic oils to stimulate the body's nerves - or olfactory receptors - to help a person feel more relaxed or energized
art therapy:
How Did Art Therapy Begin?
Visual expression has been used for healing throughout history, but art therapy didn't emerge as a distinct profession until the 1940's. In the early 20th century, psychiatrists
became interested in the artwork created by their patients with mental illness.
At around the same time,
educators were discovering that children's art expressions reflected developmental, emotional and cognitive growth. By mid-century,
hospitals, clinics and rehabilitation centers increasingly began to include art therapy programs
along with traditional "talk therapies," underscoring the recognition that the creative
process of art making enhanced recovery, health and wellness. As a result, the profession of art therapy grew into an effective
and important method of communication, assessment and treatment with children and adults in a variety of settings.
Currently, the field of art therapy has gained attention
in health-care facilities throughout the United States and within psychiatry, psychology, counseling,
education, and the arts.
For more detailed information on the history of art therapy,
please see AATA's publication list for A History of Art Therapy in the United States.
Where Do Art Therapists Work?
Art therapists work in a wide variety of settings, including, but not limited to, the
following:
- Hospitals and clinics, both medical and psychiatric
- Out-patient mental health agencies and day treatment facilities
- Residential treatment centers
- Halfway houses
- Domestic violence and homeless shelters
- Community agencies and non-profit settings
- Sheltered workshops
- Schools, colleges, and universities
- Correctional facilities
- Elder care facilities
- Art studios
- Private practice
An art therapist may work as part of a team that
includes physicians, psychologists, nurses, mental health counselors, marriage and family therapists, rehabilitation counselors, social workers, and teachers. Together, they determine
and implement a client's therapeutic goals and objectives. Other art therapists work independently and maintain private practices
with children, adolescents, adults, groups, and/or families.
What are the Requirements to Become an Art Therapist?
Personal Qualifications: An art therapist must have
sensitivity, empathy, emotional stability, patience, interpersonal skills, insight into human behavior, and an understanding of art media. An art therapist must also be an attentive listener and a keen observer.
Flexibility and a sense of humor are important in adapting to client needs and work setting.
Educational Requirements: One must complete the required core curriculum as outlined
in the AATA Education Standards to qualify as a professional art therapist. Entry into the profession of art therapy is at the master's level. Graduate level
art therapy programs include:
- Master's degree in art therapy
- Master's degree with an emphasis in art therapy
- Twenty-four (24) semester units in art therapy coursework with a Master's degree in a related field.
Contact the AATA National Office for more information concerning current educational requirements and programs.
Registration & Board Certification Requirements: The ATR and ATR-BC are the recognized
standards for the field of art therapy, and are conferred by the Art Therapy Credentials Board (ATCB). In order to qualify
as a registered art therapist (ATR), in addition to the educational requirements, an individual must complete a minimum of
1,000 direct client contact hours after graduation. One hour of supervision is required for every ten hours of client contact.
What is the Employment Outlook for the Profession of Art Therapy?
Art therapy is an expanding field and employment continues to increase as art therapy becomes recognized by professionals, work settings, and clients. Graduates of art therapy programs are successful at finding employment in both full and part-time positions.
Earning for art therapists vary geographically depending on
the type of practice and job responsibilities. Entry level income is approximately $32,000, median income of $45,000, and
top earning potential for salaried administrators ranges between $50,000 and $100,000.
Art therapists with doctoral degrees, state licensure, or who qualify in their state
to conduct private practice, have an earning potential of $75 to $150 per hour in private practice. State requirements for
private practice vary across the country, so please check with the licensing board in the state in which you plan to practice
for rules and regulations.
How Do I Find a Job as an Art Therapist?
There are a number of resources available to an art therapist
seeking employment, including college placement offices, contacts formed during internship placements, and professional organizations
newsletters and journals. Memberships in the AATA and AATA Affiliate Chapters, federal and state employers, and job information banks (such as the AATA Members Only
job postings) are also resources for employment opportunities.
What is the Difference Between the AATA & the ATCB?
The American Art Therapy Association, Inc. (AATA) promotes
and regulates the educational, professional, and ethical standards for art therapists and
is the official member organization for professionals and students in the field of art therapy. The Art Therapy Credentials
Board (ATCB), a separate organization, grants registration (ATR) after reviewing documentation of completion of graduate education
and postgraduate supervised experience.
The Registered Art Therapist (ATR) who successfully passes
the written examination administered by the ATCB is qualified as Board Certified (ATR-BC), a credential requiring maintenance
through continuing education.
avoidance: A symptom of a disorder manifested by avoiding the establishment of new interpersonal contacts to the extent that social functioning
is impaired.
avoidant personality disorder: A
pervasive pattern of social inhibition, feelings of inadequacy and hypersensitivity to negative evaluation, beginning by early adulthood and present in a variety of contexts
behavior modification: The
application of conditioning techniques (rewards or punishments) to reduce
or eliminate problematic behavior, or to teach people new responses.
behavior therapy: the
treatment method used to help patients substitute desirable responses and behavior patterns for undesirable ones
People are encouraged to learn new ways of behaving through gradual changes and exposure to feared situations. They're often asked to keep diaries to record their activities and to monitor their progress. It's particularly useful in the treatment of
phobias and anxiety.
Cognitive
Behavioral Therapy for treatment in Panic Disorder Common and effective treatments for
panic disorder are psychotherapy (cognitive behavioral therapy or psycho-dynamic therapy)
and medication.
Many people will choose a combination of therapy and medication, which can produce better results than either treatment alone.
Cognitive behavioral therapy (click underlined link to visit a site outside anxieties
101 for additional information!) generally involves:
Learning
Your psychiatrist tells you more about panic disorder, helps you identify its symptoms and teaches you about the treatment.
Monitoring
Your psychiatrist
has you monitor your symptoms with a diary or log to keep track of the timing and severity of your attacks and in what situations
they occurred.
Breathing
Your psychiatrist
teaches you ways to manage your anxiety during a panic attack. One technique is abdominal breathing, which can relax you and relieve some of the physical symptoms of an attack.
Rethinking
Your psychiatrist
helps you change the way you react to the physical symptoms during a panic attack so you see them realistically instead of fearing a catastrophe.
Part of the rethinking process involves identifying the reason for your anxiety in a given situation and then recognizing that your fears of death or catastrophe will not happen and that the fear will pass.
Confronting
Your psychiatrist helps you to expose yourself to the situations
that cause anxiety and to use the panic-control techniques you've learned.
Usually you'll start with
the situ
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