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OPINION:
ETHICS: BE VISIONARY, VISIBLE, AND VOCAL
INSIDE BOOKS:
THE TRAUMA HEART
BY LOUISE A. STANGER, EDD, LCSW, CIP, & ROGER PORTER, BA
BY JUDY CRANE
Compassion
& Self-Care
Learning to Practice
What We Preach
Compassion Fatigue
Personal Stress and Burnout
Interview: Behshad Sheldon
USJT Conference Report
June 2017 Vol. 18 | No. 3, $6.95
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L E A D E R S I N M E N TA L H E A LT H P R O F E S S I O N A L L I A B I L I T Y I N S U R A N C E
ENDORSED BY THE
AMERICAN PSYCHIATRIC
ASSOCIATION
CONTENTS
7
Letter from the Editor
27
By Gary Seidler
Consulting Executive Editor
Congruence as Self-Care:
Practicing What We
Preach
8
CCAPP
CCAPP Election Sets the Stage
for a Productive 2017
By Ryan Thomas Neace, MA,
LPC, & Jeffrey A. Kottler, PhD
By Sherry Daley
Presents the personal story of
one of the authors, defines
congruence as related to
counselor self-care, and
provides suggestions on
making self-care a priority.
NACOA
10
What’s Missing in the
Surgeon General’s Report on
Alcohol, Drugs, and Health?
By Robert Denniston
Cultural Trends
32
Addiction Counselors
in the Compassion
Fatigue Cycle
By Kathie T. Erwin, EdD, LMHC,
NCC, NCGC
Describes compassion fatigue,
lists early warning signs, and
provides risk factors for
counselors.
12
Carfentanil: The Military’s
Secret Chemical Agent
By Maxim W. Furek, MA, CADC, ICADC
Opinion
15
Ethics: Be Visionary,
Visible, and Vocal
By Louise A. Stanger, EdD, LCSW, CDWF,
CIP, & Roger Porter, BA
From Leo’s Desk
17
What is God? Part I
By Rev. Leo Booth
Wellness
19
Wellness Pointers for Recovery
from Addictive Disorders
By John Newport, PhD
36
A Phenomenological
Study of Stress and
Burnout Experienced
by Licensed Alcohol
and Drug Counselors
The Integrative Piece
21
If it’s to be
By Sheri Laine, LAc, Dipl. Ac
By Derrick Crim, EdD, LADC,
CPPR, MAPM
Discusses a study on causes of
burnout and personal and
occupational stress in licensed
alcohol and drug counselors,
provides in-depth information
on those causes, and presents
suggestions for stress reduction.
www.counselormagazine.com
3
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CONTENTS
Topics in Behavioral
Health Care
22
Well-Being and Healthy
Behaviors for Providers
By Dennis C. Daley, PhD
Counselor Concerns
24
About the Term
“Substance Dependence”
By Gerald Shulman, MA, MAC, FACATA
Ask the LifeQuake Doctor
26
By Toni Galardi, PhD
Inside Books
42
Championing
Pharmaceuticals for
Opiate Addiction:
An Interview with
Behshad Sheldon
By Andrea G. Barthwell, MD,
DFASAM, & Megan Crants, BA
Describes Behshad Sheldon’s
background, her impact on
the pharmaceutical world,
and her role in Female
Opioid-Addiction Research
and Clinical Experts (FORCE).
64
The Trauma Heart:
Stories of Survival,
Hope, and Healing
From the Journal of
Substance Abuse Treatment
By Judy Crane
Reviewed by Leah Honarbakhsh
Transitioning from
8Yhcl]ÃWUh]cbhc
Addiction Treatment:
Facilitators and Barriers
Also in this issue:
Ad Index
CE Quiz
46
59
62
By Christine Timko, PhD, &
Michael A. Cucciare, PhD
Presents the findings of a
study on patient-, provider-,
and system-level barriers
and facilitators for patients
transitioning from
detoxification to addiction
treatment, and discusses
implications.
53
Provider Self-Care
through Conscious,
Balanced Relationships
By Elisabeth R. Crim, PhD
Discusses the importance of
relationships in counselor
self-care, describes somatic
transference, and examines
early childhood factors that
contribute to counselor
burnout.
6
Counselor | June 2017
LETTER FROM THE EDITOR
Compassion
C
ompassion, according to Dictionary.
com, is “a feeling of distress and
pity for the suffering or misfortune
of another, often including the desire to
alleviate it” (“Compassion,” 2017).
This issue of Counselor focuses on selfcare issues—which include compassion
fatigue (also known as secondary traumatic stress), burnout, and stress—as
related to frontline practitioners in the
addiction and mental health fields.
In her article “Addiction Counselors in
the Compassion Fatigue Cycle” (page 32),
Kathie T. Erwin, EdD, points out that compassion fatigue is far more than “burnout,”
a somewhat glorified term of yesteryear:
Compassion fatigue is not confined to
counselors who work on the front lines
of a disaster or in other settings with
traumatized clients. The nature of
vicarious or secondary traumatization
is not linked to a place, a situation or
any direct proximity to the trauma
incident. It can catch counselors by
surprise to be catapulted into an almost
imperceptible moment of transference
when clients’ traumatic experiences
cross over into the psyche of counselors.
So what exactly is compassion fatigue?
The American Institute of Stress (AIS)
defines compassion fatigue as “the emotional residue or strain of exposure to
working with those suffering from the
consequences of traumatic events” (2017).
Further, AIS states that compassion fatigue “can occur due to exposure on one
case or can be due to a ‘cumulative’ level
of trauma” (2017).
The Compassion Fatigue Awareness
Project (CFAP) explains,
Studies confirm that caregivers play
host to a high level of compassion
fatigue. Day in, day out, workers
struggle to function in care-giving
environments that constantly present
heart wrenching, emotional challenges.
Affecting positive change in society, a
mission so vital to those passionate
about caring for others, is perceived as
elusive, if not impossible. This painful
reality, coupled with first-hand
knowledge of society’s flagrant
disregard for the safety and well-being
of the feeble and frail, takes its toll on
everyone from full-time employees to
part-time volunteers. Eventually,
negative attitudes prevail.
Compassion fatigue symptoms are
normal displays of chronic stress
resulting from the care giving work we
choose to do. . . . a strong identification
with helpless, suffering or traumatized
people or animals is possibly the
motive. It is common for such people
to hail from a tradition of . . . otherdirected care giving. Simply put, these
are people who were taught at an early
age to care for the needs of others
before caring for their own needs.
Authentic, ongoing self-care practices
are absent from their lives (2017).
Clearly, addiction and mental health
professionals are susceptible to suffer
from compassion fatigue, particularly
when they treat those who have suffered
extensive trauma.
Charles R. Figley, editor of Compassion
Fatigue: Coping with Secondary Traumatic
Stress Disorder in Those Who Treat the
Traumatized, states,
There is a cost to caring. Professionals
who listen to clients’ stories of fear,
pain, and suffering may feel similar
fear, pain, and suffering because they
care. Sometimes we feel we are losing
our sense of self to the clients we serve.
. . . Those who have enormous capacity
for feeling and expressing empathy
tend to be more at risk of compassion
stress (1995).
In another article in this issue (page
36), Derrick Crim, EdD, concludes from
his study that organizations share responsibility for counselor stress and burnout.
His findings emphasized how the need
for competence and an inability to control demanding roles and expectations
caused stress among licensed alcohol
and drug counselors. The study found
that workloads, family-work conflict, and
workplace racism affected counselors’
confidence. Further, it is suggested that
positive values and role models within
the organization may help counselors
become more proficient and gain new
skills and competencies.
In their article “Congruence as SelfCare: Practicing What We Preach” (page
27), Ryan Thomas Neace, MA, and Jeffrey
A. Kottler, PhD, point out that, ultimately,
self-care is about an attitude, a cherished
belief that we can only do our best work
taking care of others when we also take
care of ourselves.
Elisabeth R. Crim, PhD, sums it up best
in her article, “Providing Self-Care through
Conscious, Balanced Relationships”
(page 53):
To be a psychotherapist, counselor,
healer, and helper is a rich and wondrous
calling. We can continue to enjoy our
journey as healers and live vibrant lives
throughout our many roles and relationships if we can heal relationally, become
more conscious, balance our attunement
to others with attunement to ourselves, and
learn to live life in a manner that is relationally genuine, fulfilled, vibrant, and free.
References
American Institute of Stress (AIS). Definitions. Retrieved
from https://www.stress.org/military/for-practitionersleaders/compassion-fatigue/
“Compassion.” (2017). Retrieved from http://www.dictionary.com/browse/compassion?s=t
Compassion Fatigue Awareness Project (CFAP). (2017).
What is compassion fatigue? Retrieved from http://www.
compassionfatigue.org/pages/compassionfatigue.html
Figley, C. R. (1995). Compassion fatigue: Coping with secondary traumatic stress disorder in those who treat the
traumatized. New York, NY: Routledge.
Gary Seidler
Consulting Executive Editor
Counselor, The Magazine for Addiction &
Behavioral Health Professionals,
A Health Communications, Inc. Publication
www.counselormagazine.com
7
CCAPP
CCAPP Election Sets the Stage for a Productive 2017
Sherry Daley
W
ith multiple nominations and tight races for
California Consortium of Addiction Programs
and Professionals (CCAPP) board of directors positions, CCAPP started 2017 with a full board of motivated professionals. CCAPP conducted elections for
board members and district representatives, and
PDGHDSSRLQWPHQWVIRUYDFDQWSRVLWLRQVèOOLQJDOO
slots on its board of directors. The newly elected and
appointed members will help to shape the CCAPP
organization and thereby the profession and industry in California.
“I was extremely pleased with the number of great nominations we had this year,” said CCAPP CEO Pete Nielsen. “This
level of interest is indicative of how dedicated and passionate our members are about CCAPP and its role in leading the
state and the nation,” he continued.
Topping the CCAPP ticket was Alan Johnson, who now
serves as president. Mr. Johnson came with many years of
experience in the profession of substance use disorder (SUD)
counseling. He managed state contracts at HealthRIGHT 360
and provided aftercare for the criminal justice population.
Johnson has been an active leader in the alcohol and other
drug profession, where he helped to develop and refine certification and educational components for CCAPP to ensure
that highly competent professionals are performing substance
abuse treatment in the state. He took the lead as CCAPP tackled
8
Counselor | June 2017
numerous high profile issues, including the implementation
of Proposition 64, the state’s recreational marijuana statute.
“I am optimistic about 2017 and can’t wait to get the ball
rolling,” said Johnson. “I predict that we will have a historic year in which the nation will be taking notes,” he added.
Johnson took the helm as the organization sought to
shepherd the state toward an “on-demand” addiction
treatment system. Johnson and fellow executive committee members drafted a four-bill legislative package entitled
the “California Comprehensive Addiction Reform Act,” introduced in January 2017.
“It is challenging work to put all the pieces together, but I
am happy to say that we all share a vision where Californians
no longer die while waiting for treatment. This inspires us to
think beyond what was once impossible to a new future in
which addiction treatment is accessible to anyone who asks
for it,” said Johnson.
Johnson, an original architect of CCAPP’s nine-point plan
and strategic plan, will continue to implement ambitious strategies for addressing the many concerns that are important
to programs and providers. Top priorities this year include:
Q Leading and collaborating on insurance
provider benefit assignment laws
Q Improving Medi-Cal reimbursement under the
state’s organized delivery system
Q Improving professional recognition via licensure
and workforce development for counselors
Q Influencing legislative policy related to the prevention,
education, and treatment of marijuana use
CCAPP
Q Introducing legislation to support
certification of small outpatient
programs (SOPs)
Q Solving provider enrollment issues
Q Professionalizing and leading the
peer support movement
Q Collaborating with the Sober Living
Network to pass a bill requiring registration/certification of addiction
recovery residences
Q Actively participating in shaping
the six regulatory reform packages
the Department of Health Care
Services has introduced in 2016
Johnson joined Past President and
newly elected Vice President Lori
Newman on the board. During Ms.
Newman’s time as CCAPP president she
oversaw the development of CCAPP’s
legislative program, including the introduction CCAPP’s 2016 counselor licensure bill, Senate Bill 1101. She also led
the organization through the finalization
of the consolidation of the past organizations. CCAPP expressed appreciation
of Ms. Newman’s willingness to serve as
vice president of the CCAPP board and
to lend her more than twenty years of
experience as a certified counselor, program manager, executive director, and
an oral examiner for individuals taking
the TAP 21 examination at its annual
meeting in October.
“Lori has been a wonderful partner
in this organization, and instrumental
in moving CCAPP to the forefront of the
profession,” said Nielsen. “I look forward
to continuing to work with her on future
projects,” he stated.
CCAPP welcomed Jennifer Carvalho
as its treasurer. Ms. Carvalho is the
CEO of Skyway House, and is very involved in her community of Oroville,
having served on the Oroville Area
Chamber of Commerce board of directors, the Oroville Recreation Area
Advisory committee, and the Oroville
Economic Development Corporation
board of directors. Ms. Carvalho has
also served as a member of the Butte
County Behavioral Health Mental Health
Services Act advisory committee.
Warren Daniels returned to the executive committee as the secretary for the
CCAPP board. His many past achievements include serving as president of
CCAPP and CAADAC, and serving as
secretary for IC&RC. He has led the organization’s legislative program for its
first two years of existence and was a
driving force in building the coalition
that pushed for dedicating marijuana
tax revenue for addiction treatment.
The 2017 board includes members
who are new to the board, as well as
some individuals who have been a part
of the CCAPP board from the beginning
of the organization and who were instrumental in helping to shape CCAPP into
the organization that it has now become.
“Their extraordinary representation
of the profession in providing the highest credentialing standards; in ensuring representation in the legislature for
both programs and professionals; and in
fostering innovative ideas to help move
the profession forward is unparalleled,”
said Nielsen.
Newly elected district board members
included Michael Barnes from district
four and Shellie Bowman from district
one. Newly elected statewide members included Evan Amarni and Cheryl
Houk, who serve as program members.
Stephanie Sobka was also reelected to
the board as a program member. New
CCAPP credentialing board members
John Bokanovich and Tabatha Hernandez
replaced retiring members Christie
Holmes and Glendora Kirkpatrick. Daniel
Chagolla and Eric Smith returned, and
Willie Cosgrave was welcomed as new
board members to the Education Institute
board. The Education Institute board
welcomed Rose Wheeler as its chair. Rick
Alsop, Joe Aaragon, Jerry Synold, Christie
Holmes, and Glendora Kirkpatrick were
thanked for their dedication and years of
service at the annual meeting in October.
“We owe the early board members of
CCAPP a tremendous debt of gratitude,”
said Nielsen. “This group of individuals
has left a permanent mark on the future
of the profession. Their input has been
beyond valuable. Their contributions
have improved the quality of treatment
in California for generations to come,”
he concluded.
CCAPP members were excited to be
involved with the election process. Every
year valid CCAPP voting members are
given the opportunity to give input by
nominating members to the CCAPP board.
“It is exciting to see CCAPP members come together and participate in
this way in the CCAPP organization. As
a membership-driven organization, the
members are the ones that push CCAPP
forward,” said Nielsen. c
About the Author
Sherry Daley is in charge of
external affairs for counselors
and marketing for the California
Consortium of Addiction Programs
and Professionals (CCAPP). She is
also a freelance writer from the
Sacramento area.
CCAPP is unifying the addiction field
2400 Marconi Avenue
P.O. Box 214127
Sacramento, CA 95821
Education
“CCAPP is
educating
addiction
counselors by
supplying
quality options
for schools
and providers”
Membership
“CCAPP is
supporting and
advocating for
programs and
professionals
in the addiction
field.”
Recovery
Residences
“CCAPP
recognizes
quality sober
living by
registering
recovery
residences.”
T (916) 338-9460
F (916) 338-9468
www.ccapp.us
Credentialing
“CCAPP is the
largest, most
respected SUD
counselor and
prevention
specialist
certifying
organization in
California.”
www.counselormagazine.com
9
NACOA
What’s Missing in the Surgeon General’s
Report on Alcohol, Drugs, and Health?
Robert Denniston
F
rom time to time the US Surgeon General issues
reports that synthesize health research and public policy in a way intended to reach the public and
generate support for needed improvements. Having
been involved in the development of two such reports—including the paradigm-shifting “Surgeon
General’s Workshop on Drunk Driving” several decades ago—and as a member of the NACoA board
of directors, I paid close attention to the latest report, issued last fall, titled “Facing Addiction in
America: the Surgeon General’s Report on Alcohol,
Drugs, and Health.”
10
Counselor | June 2017
First of all, this is a splendid report, chock-full of statistics,
illustrations, definitions, program profiles, research and practice recommendations, and a perspective that I believe significantly advances our understanding and forthrightly identifies
our challenges, yet gives us reason for hope and optimism. In
its more than four hundred pages it covers research, prevention, intervention, recovery, and a “vision for the future” that
I hope we can all subscribe to. I recommend it highly.
But something important is missing. In its comprehensive
coverage of the issue, the report has neglected to include
children of addiction. There is no mention of these innocent
victims, either in the section on impact of alcohol and drug
problems, in the prevention or intervention sections, in statistics, in the report’s compilation of proven and promising
programs designed to address the problem or in recommendations for further research and practice.
For example, in the section “Costs and Impact of Substance
Use and Misuse,” the consequences on the individual user,
on pregnancy, and on the risks of communicable disease are
well documented, followed by specific subsections on DWI,
overdosing, intimate partner violence, sexual assault, and
rape (US Department of Health and Human Services, 2016).
Yet not a word on the one in four children exposed to alcohol addiction in the family, which can create health, social,
legal, and economic problems over a lifetime, as well as the
more acute problems of child abuse and neglect.
More than twenty-eight million Americans are children of
alcoholics; nearly eleven million are under the age of eighteen. Drinking is the primary factor in family conflict and
disruption, and the home environment of children of alcoholics is typically characterized by a lack of parenting; poor
home management; lack of family communication skills;
emotional or physical violence; and increased family stress
including work problems, illness, marital strain, and financial problems.
Why is this important? Because unless we break the cycle
of addiction—and the many problems associated with substance use disorders—these children will be at high risk of
drug and alcohol disorders themselves, as well as many
other health issues, from depression to heart disease to
cancer. As the body of research known as Adverse Childhood
Experiences (ACE) documents, the risks to the array of problems of growing up in a household afflicted by parental
substance dependence and addiction is substantial and is
transmitted intergenerationally.
Understandably, the current focus on the opioid epidemic—with some seventy-eight people dying each day of overdose and the need to get more people into treatment, with
NACOA
only ten percent of those in need of
treatment actually receiving it—absorbs
our attention and our all-too-meager resources. However, children in the midst
of parental dependence and addiction
are in harm’s way, and we as a society
have for far too long averted our eyes.
While we support expansion of
treatment as a means to recovery for
individuals as well as reduced risks
for children in their care, we must also
support children of addiction to help
them cope with their conditions and
improve the means for recovery of the
whole family.
Yet in the Surgeon General’s report,
there are no research, practice or policy
recommendations related to children
of addiction. In the concluding chapter, “Vision for the Future: A Public
Health Approach,” there is a section
entitled “Specific Suggestions for Key
Stakeholders” including individuals
and families, health care professionals, professional associations, and
health care systems, but readers will
find nary a word about children of addiction (US Department of Health and
Human Services, 2016).
Early during the report drafting stage,
Sis Wenger, the president and CEO of
NACoA, and I, along with other constituent groups, met with the Surgeon
General, Dr. Vivek H. Murthy, and were
impressed with his attentiveness and sincerity as we all made our points about
what the report should include. Some
of our colleagues pushed hard for inclusion of sometimes controversial yet
well-researched interventions such as
increased alcohol taxes and regulation
of alcohol outlet density, and those measures were thoughtfully included and
well documented. That’s brave of Dr.
Murthy. Yet looking out for the welfare
of young victims of addiction did not
make the cut. That’s regrettable.
But does it really matter that children
of addiction are left out of this report?
Absolutely, for several reasons. First,
reports from the Surgeon General—
the chief health official of the federal
government—often set priorities for
research, funding, and public policy.
To be left out has great potential for
harm, as such reports confer status on
an issue and often help set an agenda
for research and public policy.
But there is another reason for concern; this report was developed with
the direct involvement and support of
NIAAA, NIDA, SAMHSA, professional
societies, addiction researchers, and
policy experts across the country. That
this group of experts, steeped in research
and policies, could miss or plainly avoid
the consequences of parental alcohol
and drug misuse and addiction on their
children is quite troubling.
Compounding the problem is that the
Affordable Care Act, including Medicaid
expansion, which has provided increased
support for treatment, might be replaced
by the new administration’s American
Health Care Act, so it is likely that there
will be a higher priority placed on treatment availability and even less attention
to other funding needs.
But we have some good news: we
have proven interventions. For example,
Celebrating Families! is an evidencebased, skills-building program designed
for families who have been affected by
addiction. This program uses an intergenerational approach, engaging parents with substance use disorders, their
children through age seventeen, and
the children’s caregivers. The program’s
focus is to prevent children’s future addiction while also improving their mental
and physical health. The Celebrating
Families! curriculum is coordinated by
NACoA and has been implemented in
over one hundred jurisdictions.
Further, SAMHSA is reissuing its
proven effective Children’s Program
Kit, introduced in this column in the
February issue of Counselor, and is
making it available to education, prevention, and treatment programs as a
tool for providing educational support
groups for children of addiction. In his preface, Surgeon General
Murthy observes that how we respond
to this crisis is a moral test for America.
He asks, “Are we as a nation willing to
take on an epidemic that is causing
great human suffering and economic
loss? Are we able to live up to that most
fundamental obligation we have as
human beings to care for one another?”
(US Department of Health and Human
Services, 2016). Tough questions, and
the answer must be yes, but the true
test will be whether we will protect the
youngest and most vulnerable among
us. Who will march for the children
who are devastated by their parents’
addiction and do not have the power
to march on their own? c
About the Author
Robert Denniston is the vice chair
of NACoA’s board of directors.
References
US Department of Health and
Human Services. (2016). Facing addiction in America: The Surgeon
General’s report on alcohol, drugs, and health. Retrieved
from https://addiction.surgeongeneral.gov/surgeongenerals-report.pdf
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www.counselormagazine.com
11
CULTURAL TRENDS
Carfentanil: The Military’s Secret Chemical Agent
Maxim W. Furek, MA, CADC, ICADC
C
arfentanil, a dangerous adulterant covertly added to batches of illegal street heroin, was examined in the previous issue of Counselor (Furek, 2017).
Carfentanil “is a synthetic opioid that is ten thousand times stronger than morphine and one hundred times more potent than fentanyl, another
deadly synthetic opioid” (MacQuarrie, 2016). This
drug is wreaking havoc with addiction professionals
and law enforcement unprepared for the drug’s extreme potency and overdose potential.
But carfentanil is not new. Nearly two decades ago the drug
was at the center of an international controversy, steeped
in mystery and intrigue.
On October 23, 2002, “a group of heavily armed Muslim
extremists from the Russian province of Chechnya burst into
a Moscow theatre during a performance and took more than
eight hundred members of the cast and audience hostage,”
according to an article from 60 Minutes (Leung, 2003). The
attackers claimed allegiance to the Islamic militant separatist movement in Chechnya and demanded the withdrawal
of Russian forces from Chechnya and an end to the Second
Chechen War (“Moscow theater,” 2015).
Elite Russian special forces, the Spetsnaz, initiated a
rescue attempt (“Moscow theater,” 2015). They tunneled
under the theater and began to pump a secret gas aerosol
into the auditorium, which, unfortunately—along with inadequate medical treatment—killed 120 hostages and all
forty of the terrorists.
Secret Chemical Agent
That event triggered an ensuing mystery. The Spetsnaz and
the Russian government refused to identify the secret chemical
agent, which provoked international speculation (MacKenzie,
2002). Media journalists questioned if the substance was a
wartime nerve agent, banned by international law: “In the records of the official investigation, the agent was referred to as
a ‘gaseous substance.’ In other cases it was referred to as an
‘unidentified chemical substance’” (“Moscow theater,” 2015).
The identity of the drug, combining military secrecy, confusion, and conjecture, remained unknown.
Several hostages died on the way to hospital or after their
arrival, and “physicians in Moscow condemned the refusal
to disclose the identity of the gas that prevented them from
saving lives” (“Moscow theater,” 2015). Additionally, later reports “said the drug naloxone was successfully used to save
some hostages,” suggesting that the gas was an opiate-based
compound (“Moscow theater,” 2015).
12
Counselor | June 2017
Law enforcement specialist William Harry Challans offered
his own theory: “The secret weapon is a gas, a sleep agent,
and not a nerve gas as initially reported by the media and
assumed by the world. It is a derivative of fentanyl, an anesthetic gas. A double-edged sword, it enables an impossible
rescue to succeed, but is responsible for the vast amount of
innocent fatalities” (2006).
The “unidentified chemical substance” was discovered
after the British analysis of clothing and urine from the siege
casualties detected the presence of carfentanil and remifentanil on the clothing of rescued British hostages (Riches, Read,
Black, Cooper, & Timperley, 2012).
Remifentanil is a potent, short-acting synthetic opioid analgesic drug given to patients during surgery to relieve pain and
as an adjunct to an anesthetic. While opiates function similarly
with respect to analgesia, the pharmacokinetics of remifentanil
allows for quicker postoperative recovery (Riches et al., 2012).
The study published in the Journal of Analytical Toxicology
concluded,
This study provides evidence from liquid chromatography–
tandem mass spectrometry analysis of extracts of clothing
from two British survivors, and urine from a third survivor,
that the aerosol comprised a mixture of two anesthetics—
carfentanil and remifentanil—whose relative proportions
this study was unable to identify. Carfentanil and remifentanil
were found on a shirt sample and a metabolite called
norcarfentanil was found in a urine sample. This metabolite
probably originated from carfentanil (Riches et al., 2012).
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CULTURAL TRENDS
“Less Lethal Technologies”
The deadly application of carfentanil
and remifentanil was a blatant violation
of the 1993 Chemical Weapons Convention
(CWC), which “bans the use of chemical weapons in war and prohibits all
development, production, acquisition,
stockpiling or transfer of such weapons”
(Schneider, 2013). The CWC entered into
effect on April 29, 1997.
The Russian Federation, as a member-state of the CWC, undertook “never
under any circumstances” to carry out
any activities prohibited to memberstates of the Convention “to develop,
produce, otherwise acquire, stockpile
or retain chemical weapons, or transfer, directly or indirectly, chemical
weapons to anyone” (OPCW, 2005). The
Convention obliges the states to fulfill
the conditions of toxic chemicals’ use
that allow to exclude or considerably
reduce the degree of injury and gravity of consequences. However, during
the special operation in Dubrovka this
provision was disregarded (i.e., neither
the type, nor the quantity of the chemical agent helped to attain the set purpose to neutralize the terrorists so as to
rescue the hostages). The Convention
allows the use of some chemical agents
like tear gas for “law enforcement including domestic riot control,” but requires that “riot control agents” have
effects that “disappear within a short
time following termination of exposure” (OPCW, 2005).
Dubrovka represents a small part
of a larger problem. Covert operations
shrouded in secrecy and double-speak
are being conducted by global agencies.
As a means of circumventing international weapons treaties, numerous countries
are clandestinely developing “nonlethal
weapons” as articulated through a bizarre
and ambiguous terminology.
These operations have been going on
for years. According to an article in the
Bulletin of the Atomic Scientists,
In 1990, the US Army rebranded their
Incapacitating Chemical Program,
which focused on the weaponization
of fentanyl-related opioid chemicals,
renaming it the Riot Control Program.
A plan for a new chemical grenade
emerged from this work. They called
it the “advanced riot control agent
14
Counselor | June 2017
device,” but the fentanyl payload
remained the same (Davison, 2009).
After a meeting in April 2007, convened
under the title “Community Acceptance
Panel: Riot Control Agents,” representatives directed by the National Institute of
Justice (NIJ) came together “to consider
the issue of ‘nonlethal’ weapons development” (Davison, 2009). Consequently,
“Penn State University won a $250,000
contract to conduct further research into
new incapacitating chemical weapons
. . . for police use in the United States
and ‘operationalize’ these weapons”
(Davison, 2009).
In the Bulletin of the Atomic Scientists,
author Neil Davison observed,
To market these weapons as somehow
separate from the chemical and
biological weapons that are banned by
international treaties, they are being
given new, confusing names. In this
intentional narrative, chemical weapons
become “calmatives” or “advanced riot
control agents,” promoted as part of a
group of so-called “nonlethal” weapons.
Worse yet, the semantic confusions go
farther. These weapons aren’t really
weapons at all but “capabilities,”
“technologies,” and “techniques.”
Similarly, other weapons under this
umbrella lose their descriptive edge:
laser weapons become “optical
distractors,” acoustic weapons become
“acoustic hailing devices,” and electrical
weapons become “electromuscular
incapacitation devices” (2009).
The justification for these new “lesslethal technologies” was explained in
a memo from the National Institute
of Justice:
Police officers sometimes need to
control violent, combative people. Their
actions under such circumstances are
governed by use-of-force protocols.
Less-lethal technologies give police an
alternative to using other physical force
options that potentially are more
dangerous to officers and suspects. The
technologies currently in use include
conducted-energy devices (such as
Tasers), beanbag rounds, pepper spray
and stun grenades (2011).
Fentanil-carfentanil, disguised as
“nonlethal” tear gas, and used for riot
control, is among these aforementioned “technologies.”
Carfentanil wields a more sinister
potential than was previously known.
Recognized as a “nonlethal technology” with law enforcement, it has also
been unleashed as a wartime weapon
of mass destruction. Unless eradicated,
this “secret chemical agent” imported
via Mexico and China will continue to
flood the illegal drug market and kill
countless individuals. c
About the Author
Maxim W. Furek, MA, CADC,
ICADC, is an avid researcher
and lecturer on contemporary
drug trends. His rich background includes aspects of
psychology, addictions, mental
health, and music journalism.
His latest book, Sheppton: The
Myth, Miracle, & Music, explores the psychological
trauma of being trapped underground and is available at Amazon.com.
References
Challans, W. H. (2006). Moscow theater hostage
crisis. Retrieved from http://www.hendonpub.com/
resources/article_archive/results/details?id=3878
Davison, N. (2009). Marketing new chemical weapons. Retrieved from http://thebulletin.org/
marketing-new-chemical-weapons
Furek, M. W. (2017). Carfentanil’s impending tsunami of death. Counselor, 18(2), 14–5, 17.
Leung, R. (2003). Terror in Moscow: Video cameras
recorded Chechen terrorist attack. Retrieved from
http://www.cbsnews.com/news/terror-in-moscow/
MacKenzie, D. (2002). Mystery of Russian gas deepens. New Scientist. Retrieved from https://www.
newscientist.com/article/dn2979-mystery-ofrussian-gas-deepens
MacQuarrie, B. (2016). Opioid epidemic’s newest
killer is ten thousand times stronger than morphine. Boston Globe. Retrieved from https://www.
bostonglobe.com/metro/2016/10/16/region-bracesfor-arrival-new-more-powerful-synthetic-opioid/
uLdoivGZdopm468poRzU3J/story.html
“Moscow theater hostage crisis.” (2015). Retrieved
from http://crimescenedb.com/
moscow-theater-hostage-crisis/
National Institute of Justice (NIJ). (2011). Less lethal
technologies. Retrieved from https://nij.gov/topics/
technology/less-lethal/pages/welcome.aspx
Organisation for the Prohibition of Chemical
Weapons (OPCW). (2005). Convention on the prohibition of the development, production, stockpiling,
and use of chemical weapons and on their destruction. Retrieved from https://www.opcw.org/fileadmin/OPCW/CWC/CWC_en.pdf
Riches, J. R., Read, R. W., Black, R. M., Cooper, N. J.,
& Timperley, C. M. (2012). Analysis of clothing and
urine from Moscow theatre siege casualties reveals
carfentanil and remifentanil use. Journal of
Analytical Toxicology, 36(9), 647–56.
Schneider, B. R. (2013). Chemical weapons convention (CWC). Retrieved from https://www.britannica.
com/event/Chemical-Weapons-Convention
OPINION
Ethics: Be Visionary, Visible, and Vocal
Louise A. Stanger, EdD, LCSW, CDWF, CIP, & Roger Porter, BA
P
lato, perhaps the most famous of ancient philosophers, laid the groundwork for our modern social
mores. He believed that ethics were the pillars of
good human behavior. Emphasizing thoughtful consideration and wise deliberation in all matters, he
wrote that “human well-being is the highest aim of
ethical thought and action” (Frede, 2013). The world’s
ancient philosophers posited that if life is a series of
choices, ethics are the oil that greases our gears and
keeps us moving forward with integrity, dignity, and
concern. As such, ethical standards have made a
home in our daily lives.
That being stated, ethics did not always have a stronghold
in the behavioral health care field. In 1935, the American Public
Health Association raised strong concerns for the mistreatment
of African Americans in Nazi Germany (Birn & Molina, 2005).
The atrocities committed against African Americans during
WWII and the subsequent Tuskegee Syphilis Experiment—in
which the association conducted clinical studies of untreated
syphilis in black men under the guise of “free medical care”—
continued past the Civil Rights Movement. It was not until
1966 that Public Health Services established ethical regulations, and in 1979 the Belmont Report was published, summarizing ethical principles and guidelines for research involving
human subjects (OHRP, 2016). From there, the issue of bioethics emerged in the 1970s and 1980s, ushering in a new wave of
ethical considerations, backed by the public’s weary doubts
over public institutions in the wake of the Watergate scandal
and unease over the Vietnam War. Finally, in 1996 the code
of ethics for public organizations was revised. In essence, as
professions grew in behavioral health care, codes of ethics for
professionals developed.
Ethics may be defined as the shared written beliefs—individual at the micro level, group at the mezzo level, and organization/societal at the macro level—a group or individual
maintains about what constitutes correct and proper behavior.
Think of ethics as standards of conduct that guide the choices
behavioral health care experts make moment to moment as
they organize and provide care for clients. Standards of care
can be seen as licensing bodies that set standards of organizational practices (i.e., JACHO, CARF, and others). Ethics
can sometimes blur lines and come into conflict with laws.
The dubious line between ethics and laws often spur public
debate, which leads to reshaping our laws. The Civil Rights
Movement of the 1960s is a notable example of how ethical
concerns spearheaded laws to be changed.
www.counselormagazine.com
15
OPINION
In the caregiving environment, ethical
issues take many forms. Greed, malpractice, human error, and misreporting are
common. Oftentimes there is not malicious
intent when ethical red flags are raised.
For instance, unpredictable or unforeseen
events can cause the kind of human error
most would commit in similar situations.
As such, it is important for health care institutions to adopt guidelines, protocols
of behavior (i.e., a code of ethics), and a
mission statement of the organization’s
values. A code of ethics is not only useful
at the macro organizational level, but also
helps individuals as part of a group or organization at the micro level because they
can follow standards on a daily basis set
forth by the organization’s ethical code.
In trying to tackle this monumental
issue, I engaged in an ongoing qualitative
research study to shed light on the most
important ethical concerns facing our industry. The research took on the form of
interviewing movers and shakers in behavioral health care—from CEOs, marketers, clinicians, admissions officers, and
interventionists to line workers and web
designers. I asked the participants to list
their top three ethical concerns. Their responses varied, but some common themes
emerged. David Skonezny, CEO of Simple
Recovery; Denise Klein, CEO of Milestones
Ranch; David Lisconbee, CEO of Twin
Town Treatment Centers; Marsha Stone,
CEO of BRC; and Paul Alexander, CEO of
Northbound, all reported a concern for
lack of training and proper credentials for
staff, missing accreditation for treatment
centers, and concerns of misrepresentation. Scams were also mentioned—
whether online, through the insurance
companies or any other misrepresentations that cast a negative spell on the behavioral health care industry as a whole.
In total I interviewed over one hundred
people and have since heard from seventy-six others. I have also presented on the
topic at three major conferences and have
blogged about this monumental issue.
Despite an effort at the organizational and individual level to adhere to ethical standards, human flaws can lead to
breaking these standards and damaging the treatment center or organization.
There has been much discussion and
public outcry that the addiction field has
become big business for Wall Street, curious investors, and opportunistic centers
16
Counselor | June 2017
full of empty promises (Kodjak, 2016). Like
salmon running downstream, ethical dilemmas are rampant. It feels like every day
there is a new article calling out a center.
In recent years, budget restraints and a
stubborn economy have led some treatment centers and other facilities to adopt
the “heads in beds” approach, whereby
leaders of these organizations adopt misleading websites and advertisements,
overpromising and underdelivering on
services, and fake money-back-guarantees to fill their centers. Moreover, some
organizations pressure staff to fill quotas
and meet deadlines all at the expense of
quality of care.
Despite an effort at the
organizational and individual level
to adhere to ethical standards,
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breaking these standards and
damaging the treatment center
or organization.
And with the move to an online
presence, misrepresentations on the
Internet such as high-definition “doctored” photos, fake positive reviews,
and misrepresented facility locations
have tricked unsuspecting clients seeking help. When I interviewed Wes Jones,
CEO of Incredible Marketing, a digital
marketing agency for medical professionals, he articulated how easily the
web can be manipulated with false impressions of treatment centers and the
services and amenities they offer (L. A.
Stanger, personal communication, July
18, 2016). In addition to fraudulent websites, 1-800 help lines have also usurped
ethical providers, funneling good providers’ resources to phantom call centers that
have nothing to do with them. I recently
fell prey to this type of unethical practice,
and Five Sisters Ranch in Petaluma did
too, amongst similar reports throughout
the behavioral health care field.
Kickbacks and referrals are major
issues in the overly complicated health
care system in this country. A referral
occurs when clinicians or professionals
refer clients to a behavioral health care facility in which clinicians have a financial
interest. Likewise, kickbacks can occur
when someone offers money for patients
or when insurance is used in a way that
pays for both outpatient and sober living.
I myself have been twice offered, at conferences, substantial funds (promises of
$300,000 per year) for referring patients
to a specific lab. Also, there are reports of
overbilling of lab charges. For example,
I recently heard from one family which
verified they were charged by the provider $13,500 in one month for three lab
tests for alcohol—a typical sobriety test
runs at $150.00 per test. And then there
are the insurance companies that set fees
which can dictate terms of care. In turn,
some providers may misrepresent their
claims, making it all the more challenging
for the providers who are ethical.
As a result of kickbacks and other unethical practices, Congress passed the
Stark Law, a series of provisions that ban
referrals and kickbacks in the health care
field (CMS, 2015). Furthermore, this law
has inspired many organizations to examine and enhance their code of ethics
to deter individuals and organizations
from slipping into these types of ethical
dilemmas. When communities come
together to bolster our collective social
conscience, it challenges everyone to
uphold the values we hold dear in our
homes and workplaces.
With ethical uncertainties posing a
threat to behavioral health, let’s take a
moment to investigate an ethical model
that is easy to teach and implement and
can help shape the way we work in the
behavioral health community. Elaine
Congress, a professor and social worker,
developed the Congress model, which
uses an acronym to employ a collection
of guideposts for groups and individuals in the behavioral health field to consider when faced with ethical dilemmas:
Q E - Examine relevant personal,
societal, agency, client, and
professional values
Q T - Think about what ethical
standard of the National Association
of Social Workers (NASW) code of
ethics applies, as well as relevant
laws and case decisions
Q H - Hypothesize about possible consequences of different decisions
Continued on page 18
FROM LEO’S DESK
What is God? Part I
Rev. Leo Booth
I
realize that many people reading this article may
be surprised that I have titled it “What is God?”
rather than “Who is God?” Well, I have my reasons.
In June 2016 I wrote an article for Counselor
titled “A Spiritual Revolution,” and that
has been followed by subsequent
articles titled “Prayer: What is it?”
and “God’s Grace: What is it?” In
light of these published articles,
I think it is appropriate to ask
the $64,000 question: What
is God?
I have devoted most of my years in
recovery to the question, “What is spirituality?” and my views on this exciting topic
have changed over the years. Also, my views concerning my relationship and understanding of God have
also changed. Who knows what I will be writing in the
coming years!
If we look at some of the definitions that have been offered over the years we will find the following:
Q The Free Dictionary suggests that God is “A being
conceived as the perfect, omnipotent, omniscient
originator and ruler of the universe” (2017). The
Merriam-Webster dictionary says,
“The Being perfect in power,
wisdom, and goodness who is
worshipped as creator and
ruler of the universe” (2017).
So, I ask myself, where did
they get these theological
definitions from? Well,
they got them from what
traditional religions have
said and believed.
Q Judaism teaches two aspects
of God: the unknowable and
the revealed God who created
everything and interacts with
creation.
Q Christianity agrees with Judaism, but
goes on to teach God as the Trinity:
Father (Creator), Son (Redeemer),
and the Holy Spirit (Sustainer).
Q Islam suggests that God is the one and only: He begetteth not, nor is He begotten.
Q Buddhism is more fluid and suggests that the spiritual life
seeks to alleviate any distress. It neither denies nor accepts
a creator and goes on to further suggest that questions
on the origin of the earth are worthless!
Q Hinduism is extremely complex and
comprehensive, incorporating all the
above theories, but is dependent upon
the geographical tradition found in
the many parts of India.
These are some of the ingredients
that make up the “God Cake,” and
I can certainly see why people in
recovery, depending upon their religious traditions, if any, often think
of God as confusing, baffling, and most
difficult to understand!
But let us remember there have always
been, in history and today, thinkers who dared
to question, disagree or object to the aforementioned teachings. They were called “heretics.” For me,
the title “heretic” does not mean that they are wrong—on
the contrary, they simply dared to think differently. In
my book, The Happy Heretic, I quote Pelagius, who said,
“That we are able to do good is of God, but that we
actually do it is of ourselves. That we are able to make
a good use of speech comes from God; but that we do
actually make this good use of speech proceeds from
ourselves” (2012, p. 51).
Description, Not a Name
It took me a long time to realize that “God” is not a
name like “Leo,” “Ann” or “George.” Rather, it is a term
and a description that seeks to explain the unexplainable.
Religious or spiritual people seek to know the unknowable. The belief has slowly taken root that in seeking to
understand God they begin to understand themselves.
But does it need to be so complicated? And does
what is being said concerning God make sense to what
we see and how we live our lives? I think not.
Rumi, a Muslim thinker, makes it so much simpler when
he says, “God is in me and I am in God. I am in you and
you are in me. We all reflect God” (Booth, 2012, p. 29).
The Baggage
With God, for many people, comes the baggage of
Hell, Heaven, sin, fear, right, wrong, immortality, devils,
angels, grace, prayer, heretic, saint . . . the list could go
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17
FROM LEO’S DESK
on and on and has tragically damaged
so many people.
In my previous articles, I touched on
this baggage and offered a solution that
makes sense to me.
Concerning Prayer
When I pray, the essential ingredient
is that I hear my prayers. For example, if
I am praying for a job, I need to search
out the necessary qualifications required
and fill out the application form!
It took me a long time
to realize that “God” is
not a name like “Leo,” “Ann”
or “George.” Rather it is a
term and a description
that seeks to explain the
unexplainable.
Concerning Grace
I do not believe that grace is
something that mysteriously falls upon
us, I believe that it has been given to us
at birth. God’s grace becomes akin to our
reasoning powers, our ability to think and
make choices, and our ability to take responsibility for our lives.
Concerning God
The divine is in creation, beyond creation, in you, and most definitely in me.
This will require my imagination, that
poetic aspect of our mind that enables
the created to create. God’s kingdom
is within. c
About the Author
Leo Booth, a former Episcopal
priest, is today a Unity minister. He
is also a recovering alcoholic. For
more information about Leo Booth
and his speaking engagements, visit
www.fatherleo.com or e-mail him at
fatherleo@fatherleo.com. You can
also connect with him on Facebook:
Reverend Leo Booth.
References
Booth, L. (2012). The happy heretic: Seven spiritual insights for healing religious codependency. Deerfield
Beach, FL: Health Communications, Inc.
The Free Dictionary. (2017). God. Retrieved from http://
www.thefreedictionary.com/god
Merriam-Webster. (2017). God. Retrieved from https://
www.merriam-webster.com/dictionary/god
18
Counselor | June 2017
Opinion
Continued from page 16
Q I - Identify who will benefit and
who will be harmed in view of
social work’s commitment to the
most vulnerable
Q C - Consult with supervisors and
colleagues about the most ethical
choice
As Congress points out in her paper
“What Social Workers Should Know
about Ethics,” treatment centers, facilities, and others in the field can use the
model to turn their values as an organization into a code of ethics for staff
and clients to follow. “A social work
value,” writes Congress, “has little value
unless it can be translated into ethical
practice” (2000). This is key: working
an organization’s ethics into its culture
and daily duties and responsibilities.
Although ethical challenges are the
glue that pieces society together, there
are opportunities for professionals in
behavioral health to advance a code
of ethics for their organizations, which
permeate into our homes and communities. As such, in accordance with the
Congress model and an uncanny fiftyplus years working in behavioral health
(believe it or not I was licensed as a clinician in 1973, BBS 4451), I’ve developed a
standard of care challenge for individuals and organizations to implement in
their behavioral health setting:
Q Develop a mission statement
for your organization
Q Articulate the organization’s values
and obtain appropriate licensure
Q Develop or revisit your organization’s ethical code of conduct
Q Let the world know your mission,
values, and ethical statement,
and put it on your website
Q Use the back of your business
card for your mission statement
Q Work tirelessly to elevate the
behavioral health care field. If
you don’t, the field will fail.
Along with these steps, please be
sure to:
Q Review your individual
professional ethics based on
your licenses and certifications
Q Sign the Hayes-Davidson
Ethics Pledge
Q Sign the Fair Practices Act Pledge
Q Engage in continuing education
The challenge is clear and I empower everyone to put it to action.
Remember to be visionary, visible,
and vocal in your organizations and
to not let greed and malfeasance outweigh the good we as health care professionals can do for others. c
About the Authors
Louise A. Stanger, EdD, LCSW,
CDWF, CIP, received her bachelor’s
degree in English literature from the
University of Pittsburgh, her master’s
in social work from San Diego State
College, and her doctorate in educational leadership from the University of San Diego. Her
book Falling Up: A Memoir of Renewal is available on
Amazon. You can contact Louise at drstanger@allaboutinterventions.com.
Roger Porter, BA, has two bachelor
degrees (film and marketing) from
the University of Texas at Austin. He
works in the entertainment industry,
writes screenplays and coverage, and
when he’s not doing that he tutors
middle and high school students.
You can contact Roger at raporter15@gmail.com.
References
Birn, A., & Molina, N. (2005). In the name of public
health. American Journal of Public Health, 95(7), 1095–7.
Centers for Medicare and Medicaid Services (CMS).
(2015). Physician self-referral. Retrieved from https://
www.cms.gov/Medicare/Fraud-and-Abuse/
PhysicianSelfReferral/index.html?redirect=/
PhysicianSelfreferral/
Congress, E. P. (2000). What social workers should
know about ethics: Understanding and resolving
practice dilemmas. Advances in Social Work, 1(1).
Retrieved from https://journals.iupui.edu/index.
php/advancesinsocialwork/article/viewFile/124/107
Frede, D. (2013). Plato’s ethics: An overview. In E. N.
Zalta (Ed.), The Stanford encyclopedia of philosophy.
Retrieved from https://plato.stanford.edu/archives/
win2016/entries/plato-ethics/
Kodjak, A. (2016). Investors see big opportunities in
opioid addiction treatment. Retrieved from http://
www.npr.org/sections/health-shots/2016/06/10/
480663056/investors-see-big-opportunities-inopioid-addiction-treatment
Office for Human Research Protections (OHRP).
(2016). The Belmont report. Retrieved from https://
www.hhs.gov/ohrp/regulations-and-policy/
belmont-report/
WELLNESS
Wellness Pointers for Recovery
from Addictive Disorders
John Newport, PhD
A
distinctive feature of recovery from addictive disorders is that while people entering recovery have reached a point where
they are powerless over the addiction per se,
they must assume central responsibility for
holding the addiction at bay.
In keeping with this issue’s focus on self-care,
this column is intended to provide suggestions for
your clients concerning practical steps they can take
to maximize the benefits derived from integrating a
wellness lifestyle into their recovery. The following pointers are designed to assist people at all
stages of recovery in embracing a wellness lifestyle. These suggestions are meant to apply to
most persons in most situations. In the event
of preexisting health problems, clients are
urged to consult with their primary health care
providers concerning the applicability of these and
any other wellness suggestions.
Nutritional Foundations
Q Sound nutrition is a prime cornerstone of lasting sobriety. Many recovering alcoholics suffer
from alcohol-induced hypoglycemia. To help
normalize your blood sugar, eat three small,
wholesome meals a day, interspersed by three
nutritious snacks. A balanced diet, which emphasizes fresh vegetables, fruits, grains, and
lean sources of protein, is highly recommended. Lessen your dependence on animal products by eating complementary sources of
plant-based protein.
Q Go lightly on (or eliminate) nutritional stressors including caffeine, refined sugars, and
white flour products. It is also advisable to cut
back on meats, dairy products, and other
high-fat foods.
www.counselormagazine.com
19
WELLNESS
Q Maintain your proper weight
through a combination of balanced
diet and exercise.
Q Consider taking a daily multivitamin supplement, and possibly
making judicious use of other
health-conducive natural supplements. Remember, however, that
supplements are not a substitute
for a balanced, nutritious diet.
Fitness and Recovery
Q A regular program of vigorous exercise is highly recommended for cardiovascular endurance and overall
positive health. Vigorous exercise
safeguards against relapse and releases endorphins, giving you a
natural, drug-free high!
Q I firmly believe a regular program of
balanced exercise is by far the best
health insurance we can give ourselves! Choose an exercise you enjoy,
otherwise you won’t stay with it.
Q If you choose walking, build up to a
program of forty-five minutes, five
to seven days per week. If you
prefer more vigorous exercise—running, swimming or aerobic dance—
a regimen of three to five, twenty- to
thirty-minute workouts per week is
recommended.
Q Set aside several minutes each day
for stretching exercises for flexibility. Ideally, you should also work
in a muscle-toning exercise session like weight lifting or other resistance training three to four
times per week.
Stress Management and
Social Supports
Q Practice the Serenity Prayer
throughout the day. In my opinion,
this is the most powerful stress
management tool available.
Q Recognize that clear and harmonious communications are essential
to stress reduction and sobriety
maintenance, as most stresses in
our lives arise from lack of harmony
in our communications with others.
Q Learn the art of self-nurturance and
giving and receiving position
strokes. Get (and give) at least five
hugs per day!
20
Counselor | June 2017
Q Set aside a daily mind-quieting
period, ten to twenty minutes, for
meditation, prayer, listening to relaxing music or just sitting quietly.
Yoga and tai chi are excellent forms
of moving meditation.
Cancer Society, the American
Lung Association, and other
sources. Call a smoking cessation
counselor at the National Cancer
Institute’s Smoking Quit Line at
1-877-44U-QUIT.
Q Cultivate mindfulness—the art of
truly being in the here and now,
while releasing obsessive thoughts
focused on the past or future.
Spending time in nature provides
an excellent opportunity to fully experience the state of mindfulness.
Q Be persistent—the average smoker
quits five times before kicking the
habit for good.
Q Learn the art of time management
and avoid overscheduling yourself.
Consciously schedule some “slack
time” into your daily routine.
Recognize that clear
and harmonious communications
are essential to stress reduction
and sobriety maintenance,
as most stresses in our
lives arise from lack of harmony
in our communications
with others.
Q In work-related pursuits, remember
that opportunities for personal fulfillment and loving service are infinitely more important than
attempting to maximize your financial gain.
Q Be sure to get seven to eight hours
of sleep each night. If you suffer
from insomnia, ask yourself if you
are consuming too much caffeine
or sugar.
Q Seek out others and deepen your
friendships by being a good friend.
Actively participate in a recoveryfocused support group.
Conquering Nicotine Addiction
Q Cigarette smoking is the leading
preventable cause of death among
people in recovery. If you are struggling to free yourself from nicotine
addiction, discuss your desire to
quit with your doctor.
Q Check out low-cost smoking cessation support groups offered by
your health plan, the American
Spirituality and Quality of Life
Q Work to deepen your relationship
with your higher power through
prayer, meditation, and whatever
else works for you. Frequently turn
to your higher power for guidance
and seek out opportunities for
loving service.
Q Appreciate the connection
between personal fulfillment
and positive health. It is no
coincidence that throughout
history great leaders—together
with highly successful composers,
artists, and other people driven
by a passion for creative fulfillment—have frequently enjoyed
long life spans.
Q Strive to find and express your
unique sense of purpose in life, and
strike a healthy balance between
work, relaxation, and creative pursuits. Remember, the purpose of life
is a life of purpose.
Q Like recovery, wellness is a lifelong
process of growth and development. Enjoy the journey!
I hope these pointers enhance your
appreciation of the many creative steps
your clients can take to maximize their
enjoyment of high-quality sobriety. As
always, feel free to share these guidelines
with your clients and others who benefit
from the message. Until next time—to
your health! c
About the Author
John Newport, PhD, is an addiction specialist, writer, and speaker
living in Tucson, AZ. He is author
of The Wellness-Recovery
Connection: Charting Your Pathway
to Optimal Health While Recovering
from Alcoholism and Drug
Addiction. You may visit his website www.wellnessandrecovery.com for information
on wellness and recovery trainings, wellness coaching by telephone, and program consultation services
that he is available to provide.
THE INTEGRATIVE PIECE
If it’s to be
Sheri Laine, LAc, Dipl. Ac
H
ow does one learn to live a life of emotional,
mental, and physical self-care, when days of not
caring have turned into years or even decades?
As my patient—let’s call her Sharon—and I were
talking, while her acupuncture needles were in
place, I noticed from her words that the choices
she made as a young woman still held her hostage
as a mature adult.
Sharon presented to my clinic with chronic constipation
and urinary difficulties caused by a nervous bladder. As the
mother of three teenagers, and with a part-time job as a successful fashion stylist, Sharon’s days are very busy. She is
now in a loving partnership with a man who appreciates
her and is truly her best friend.
Sharon’s early years as a young mother were spent caring
for her children. Her husband at the time was abusive, narcissistic, and controlling. He refused to help her with the
home and hearth. He barely contributed to their financial
well-being, leaving most of the responsibilities to her. As a
result, Sharon has suffered through many years of anxiety.
Another one of my patients—we’ll call her Linda—struggles with her weight. Aware that the extra pounds are starting to take a toll on her health, Linda too is still held hostage
by her past, this time a childhood of neglect by her mother
and an absent father.
What these two women have in common is an issue shared
by many: problems letting go of the past mentally, emotionally, and physically.
Interestingly, both Sharon and Linda suffer from liver qi
stagnation. In Chinese medical physiology, the liver is responsible for storing the blood and regulating the movement
and flow of qi, the life force within the body. A healthy, wellfunctioning liver regulates the other organs as it performs
its job of spreading qi, blood, and oxygen.
The liver also houses the ethereal soul, which is said to
influence our sense of life direction, our emotions, and our
capacity to plan life’s pursuits. With this in mind, I zeroedin on the liver as I started to treat both patients.
In addition to weekly acupuncture treatments, I had both
women commit to a five-times-per-week outside walking program lasting up to one hour and no less than thirty minutes.
Walking is the exercise of the liver, as it encourages the free
flowing of qi within the body. I asked that they pay attention
to their thoughts while they were walking. If they experienced
negative thoughts or sadness creeping in, I suggested they
substitute defeating thoughts with positive, happy, empowering ones about family, friends, happy experiences or success
in their work. Most importantly, I encouraged them to stay in
the moment with their empowering thoughts during exercise,
and to take long, languid, deep, cleansing breaths while doing
so. I also asked them to focus on their outside surroundings,
taking in the beauty of nature as they were walking.
In essence, I asked both women to begin to practice a
walking meditation. If they had the time, I also encouraged
a stretching program.
It goes without saying that I designed a dietary program
for them as well, including fresh organic seasonal greens,
vegetables, fruits, warmed squashes, and soups daily for at
least three of their meals. I also reduced the amount of simple
carbohydrates and increased the amount of legumes, nuts,
healthy fats, and whole grains. I recommended that the first
meal of the day include a light protein and healthy fat combo.
Cognitive awareness therapy also works well with the
types of mental and emotional disorders presented by both
Sharon and Linda. I encouraged both women to seek a therapist who specializes in inner-child work.
My patients are showing significant improvement. They
both report enhanced elimination, weight loss, and better
functioning, emotionally and in their lives overall.
Now, I see two happier, and healthier women coming into
my clinic every week. For even better results, I have recommended that they give themselves a full year of therapy, treatment, and exercise. C
About the Author
Sheri Laine, LAc, Dipl. Ac., author of Living the EnerQi Connection,
is a California-state and nationally certified acupuncturist and herbologist licensed in Eastern medicine. She has been in private clinical practice in Southern California for twenty-five years. In addition
to teaching, Sheri speaks throughout the country about the benefits
of integrative living and how to achieve a balanced lifestyle. Please
visit her at www.balancedenerqi.com.
www.counselormagazine.com
21
TOPICS IN BEHAVIORAL HEALTH CARE
Well-Being and Healthy Behaviors for Providers
Dennis C. Daley, PhD
G
oogle the terms “well-being,” “self-care,” “wellness”
RUÚKHDOWKEHKDYLRUVÛDQG\RXZLOOèQGPLOOLRQV
of entries including lists of ways to care for our physLFDOHPRWLRQDOVSLULWXDOVRFLDODQGèQDQFLDOKHDOWK
7KHJURZLQJèHOGVRISRVLWLYHSV\FKRORJ\DQGOLIHstyle medicine have brought attention to the importance of “active engagement,” or taking positive
steps to prevent, manage, and improve medical or
psychological conditions (Bolier et al., 2013; Hibbard
& Green, 2013). Good self-care and healthy behaviors are associated with a decrease in the risk of disease and health problems; improved physical and
mental health; and a better quality of life. If you have
a health condition, self-care and good health habits
enable you to more effectively manage it. Well-being
is also associated with reduced medical costs and
EHWWHUSURèWVIRUEXVLQHVVHV)R[+LEEDUG
Green, 2013).
While there are different definitions and conceptual frameworks that identify and discuss well-being or health behaviors, many of these overlap. Let me provide some examples.
Examples
The National Wellness Institute (NWI) defines wellness
as “an active process through which people become aware
of, and make choices toward, a more successful existence”
(2017). The six dimensions of wellness promoted by NWI
are as follows:
helps negate negative emotions and lead to happiness
and satisfaction)
2. Engagement (involvement in tasks or activities that bring
satisfaction, pleasure, ecstasy or comfort)
3. Positive relationships (loving connections with others
that help us deal with life’s difficulties)
4. Meaning or purpose in life (serving something larger
than ourselves)
5. Accomplishments or achievements (pursuing success or
mastery for their own sake)
Anderson and Anderson (2003) state that health and longevity are affected by overall well-being in six domains:
1. Biological and lifestyle (activity, diet, smoking, drinking)
2. Psychological or behavioral (thoughts, actions, response
to trauma)
3. Emotional (positive emotions, dealing with the most
problematic emotions of depression/sadness, anxiety/
fear, anger/hostility)
4. Economic (achievement, economic equality, education,
income)
5. Environmental and social (housing, safety, neighborhood, relationships)
6. Existential, religious or spiritual (beliefs and actions that
foster faith and meaning in life)
Engaging in self-care or healthy behaviors to improve
well-being are not one-time events, but things that are best
incorporated into our daily lives. Sustaining these behaviors
over time enables us to meet our needs, manage stress and
emotions, soothe ourselves, and engage with positive people
and in positive experiences and activities that are meaningful and healthy.
1. Occupational (choosing a rewarding career)
For Those in Helping Professions
2. Physical (eating healthy foods, being physically fit)
Those of us who work in medical, behavioral health or
social service settings often work with complex problems
that require time, energy, attention, and skill on our part.
Due to the nature of our work in “giving” so much to others,
it is easy to ignore our needs or our well-being. In addition
to a career helping others, many of us care for children,
grandchildren or a sick or aging family member. Some of
us have special needs children or adult children who are
struggling in life and not very successful. Others have excessive demands at work or difficult coworkers. Some of
us have medical, psychological or financial stressors. Any
one or combination of these can overwhelm us, especially
if we lose ourselves in the process or do not focus on our
3. Social (contributing to the welfare of the community)
4. Intellectual (engaging in creative and stimulating mental
activities)
5. Spiritual (meaning in life, living in a way that is consistent with our values and beliefs)
6. Emotional (being aware of and accepting our feelings,
being optimistic)
Seligman (2012) promotes five elements of well-being:
1. Positive emotion (the cornerstone of well-being that
22
Counselor | June 2017
TOPICS IN BEHAVIORAL HEALTH CARE
needs and seeking help or support from
others. Employee assistance or wellness programs, or a personal coach or
therapist can help us make and sustain
positive health behaviors that improve
our well-being.
Rather than provide a list of strategies to improve well-being, I will briefly
share some of what I do to stay healthy,
manage stress, reduce negativity, and increase positivity. I have made many mistakes during my lifetime by not paying
sufficient attention to my well-being and
health, so I hope sharing my experiences may get you thinking about your own
well-being.
Physical Health and Exercise
Much has been written about the
benefits of exercise and physical health
behaviors, including rest and sleep
(Ratey & Hagerman, 2013; Huffington,
2014). I’m in the later third of life (i.e.,
over the age of sixty) so I get regular
physical examinations, follow a decent
diet, and exercise nearly every day. For
years I struggled with sustaining regular exercise beyond a few months until
I walked in the woods with a retired
friend in his seventies who was in excellent shape. His secret was simple, so
I adopted it immediately: walk and/or
run every day rather than three or four
days a week, since I often stopped after
several months. Each day I “make” time
to run or walk rather than “find” time,
so exercise is now a daily ritual. I track
my mileage and steps along with a small
group, and we encourage each other to
keep active or fight through struggles. I
mix it up in terms of places I walk and
run. I also enjoy my walks with a friend
during which time we solve the problems
of the world. From daily walking and
running I feel better physically and mentally. Although losing weight was never
my goal, I lost over twenty-five pounds.
me down as I have learned not to get
angry, anxious or upset over things that
are not worth it or that I cannot control. I focus on feeling and expressing
positive emotions like gratitude, joy
or love. I try not to take my blessings
for granted, so I express gratitude and
positive emotions to let others know
how I feel and what I appreciate about
them (See Emmons, 2013 for a review
of strategies to increase gratitude and
benefits of doing so). I limit my time
with people who complain chronically
or are too negative, and spend my time
with people whose company I enjoy. I
also mentor young people at work or
in my family as a way of giving back
and sharing my experiences.
Savoring Life’s Joys, Playing,
and Having Fun
There are many things I savor in life
related to the senses—hearing, tasting,
smelling, seeing—and I usually live in the
moment rather than project in the future. I
savor meaningful connections with others.
For example, being with my grandchildren brings me indescribable joy. There is
nothing like being awakened at 6:00 am
by a four-year-old to play, then later hike
in the woods to look for spiders and enjoy
nature. Or, having a sixteen-month-old
bring me a book and sit on my lap while
I read it. Or, holding or feeding an infant.
Such experiences are meaningful and extraordinary, and speak to the importance
of play and fun with others.
I grew up in a poor family and did
not learn about budgets or financial
management. As a result, I made about
every mistake one can make, so I am
aware of bad money habits, as well as
the importance of financial competence.
Fortunately, I made significant changes
and have a few suggestions since spending habits affect health and the quality
of life. First, live within your means and
don’t spend money you cannot afford on
gifts or things you do not need or your
budget can’t handle. Second, invest in
retirement and save as much as you can
now or you will regret it. Third, follow
a budget and find “little” ways to cut
down on spending. Fourth, find low interest loans, consolidate multiple debts
once only, avoid long-term mortgages if
possible, and review your financial plan
regularly. I know many people who have
a serious problem in their primary relationship due to poor money management.
Intellectual Growth
I remain curious about many things
in life. I consciously cultivate this by pursuing many interests, reading, learning
from others, engaging in stimulating
discussions, being creative, and refusing to be bored at home or work. I have
discovered many exceptional websites
and resources that help me learn and
expand my horizons.
Continued on page 25
Serving the Inland Empire for over 25
years, we provide multi-level care in the
following areas:
• Chronic pain and
medication dependency
• Eating disorders
• Chemical dependency services
• Adolescent self injury
• Mental health services unique to youth,
adults and seniors
Emotional and Interpersonal Health
Much has also been written about
the benefits of decreasing negative and
increasing positive emotions, stopping
harmful relationships, staying connected with supportive people and focusing on love relationships (Seligman,
2012; Emmons, 2013; Fredrickson,
2013). I no longer focus much energy
on negative emotions or let these pull
Financial Health
We LIVE
to Hope
For more information or to
make a referral, please call
909-558-9275 or visit us on
the web at llubmc.org.
MANY STRENGTHS.
ONE MISSION.
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23
About the Term “Substance Dependence”
Gerald Shulman, MA, MAC, FACATA
T
he term “substance dependence” is very com- Notice that no distinction is made between “submonly used. In fact, it was one of the two listed stance dependence” and “physiological dependence.”
substance use disorders (SUDs) in the DSM-IV (APA,
For example, because of the confusion between addiction
1994), which included “substance abuse” and “sub- and substance dependence on the one hand and physiologidependence on the other, some clinicians are unwilling
VWDQFHGHSHQGHQFHÛ7KLVFODVVLèFDWLRQZDVUHFHQWO\ cal
to suggest antiaddiction medications, particularly agonists
replaced in the DSM-5 (APA, 2013) with the term like methadone or buprenorphine or even antagonists like
“substance use disorder” with three levels of severity: naltrexone or the extended-release, injectable formulation of
naltrexone, Vivitrol, to treat opioid dependence. The reasonmild, moderate or severe. The term “substance ing behind this refusal comes from the notion that if people
dependence” is often used interchangeably with are using a drug (the agonist), they are still addicted. In reality, when using agonist drugs, if individuals are not abus“addiction,” yet the two can be very different. Both of ing their agonist or any other psychoactive substance, they
these terms are often inaccurately applied to mean remain physiologically dependent. Consider patients who
physiological dependence. This confusion can result use an opioid as prescribed for a couple of months, and who
have not abused it or any other psychoactive substances.
in communication problems among clinicians and Upon abrupt discontinuation, they are likely to suffer opioid
treatment decisions that are not in the best interest withdrawal symptoms, but because they are not addicted
and showing characteristics of compulsion, loss of control,
of patients. This confusion is furthered by the profes- continued use in spite of adverse consequences, and cravsional literature. For example, “Addiction is a condi- ing, they do not go looking for a fix.
In both the DSM-IV and DSM-5, two of the diagnostic crition in which the body must have a drug to avoid teria
for dependence include an increase in tolerance and the
physical and psychological withdrawal symptoms. presence of a withdrawal syndrome, both indications of phys$GGLFWLRQØVèUVWVWDJHLVGHSHQGHQFHÛDSSHDUVLQWKH iological dependence. However, in the DSM-IV, individuals
could meet three of the seven criteria for dependence without
American Psychological Association’s publication the meeting the ones for tolerance or withdrawal. In the DSM-5,
APA Addiction Syndrome Handbook (Shaffer, 2012). people could meet six or more of the eleven diagnostic criteria
24
Counselor | June 2017
COUNSELOR CONCERNS
indicating a severe level of SUD, again
without meeting the criteria indicating
physiological dependence. Clearly, substance dependence or addiction may be
related to physiological dependence, but
the three are different terms, although
more than one may be applicable to the
same situation.
Consider drugs not usually considered
to be addictive. Take the case of individuals who use a beta blocker to control
blood pressure for some period of time
and then suddenly stop. The result is a
spike in blood pressure and pulse, maybe
tremors, and possibly a fatal heart attack.
Or if people use Dilantin for the control
of seizures and suddenly stop, they will
experience an increase in seizures above
baseline, and perhaps one that could be
fatal. Could this be withdrawal or perhaps a rebound phenomenon?
If individuals use an addictive substance long enough and heavily enough
to be able to show withdrawal symptoms
when they stop, that alone is evidence of
physiological dependence. Conversely,
the presence of a withdrawal syndrome
when using a psychoactive substance
says nothing about whether individuals
should be considered addicted.
Further complicating and confusing
the issue of what should be clear distinctions between these terms is the addition of gambling to SUDs in the DSM-5.
In the DSM-IV, “pathological gambling”
was considered an impulse control disorder (APA, 1994). It is now classified as
“gambling disorder” in the DSM-5 and
listed under the category of “substance
use and addictive disorders” (APA, 2013).
While I would have no disagreement that
gambling can become an addictive disorder, what has occurred since the publication of the DSM-5 is that all of the
disorders in this category have come to
be regarded as addictions, including all
severities of SUDs.
For example, if individuals were to be
diagnosed with an alcohol use disorder,
mild, in the DSM-5, this would be comparable to the diagnosis of alcohol abuse in
the DSM-IV. When speaking about abuse,
it is helpful to consider this as intentional drinking or drug use and intoxication.
Clearly, college students who set out to
get high, “smashed” or drunk were motivated to achieve that state. They made
a conscious decision to achieve this end
result, which is not the consequence of
loss of control or compulsion or craving.
This change in considering a mild severity of SUD as an addiction would likely
add twenty million people as addicts
(Frances, 2013).
Abusive, heavy or binge drinking
might result in a hangover. But a hangover is very different from withdrawal.
The symptoms associated with a hangover (e.g., headache, nausea, dizziness,
and cotton mouth) are the results of ingesting a large amount of a toxic substance: alcohol. Withdrawal, on the
other hand, is defined as “a maladaptive behavioral change, usually with
uncomfortable physiological and cognitive consequences, that is the result
of cessation or reduction in heavy and
prolonged substance use” (Reis, Fiellin,
Miller, & Saitz, 2014). The last thing that
individuals suffering from hangover
symptoms want do is drink the next
morning, although they may do so to
treat their symptoms with “the hair of
the dog that bit you.”
I would like to suggest a replacement
for the term “substance dependence,”
Topics
but cannot find a good substitute. In the
meantime, what we can do is use these
terms precisely and appropriately. c
Acknowledgements: My thanks to Steve Coulter, MD,
for his thoughts on this matter.
About the Author
Gerald Shulman, MA, MAC,
FACATA, is a clinical psychologist
and fellow of the American College
of Addiction Treatment
Administrators. He has been providing treatment or clinically or administratively supervising the delivery of
care to alcoholics and drug addicts since 1962.
References
American Psychiatric Association (APA). (1994).
Diagnostic and statistical manual of mental health disorders (4th ed.). Washington, DC: Author.
American Psychiatric Association (APA). (2013).
Diagnostic and statistical manual of mental health disorders (5th ed.). Washington, DC: Author.
Frances, A. (2013). Saving normal: An insider’s revolt
against out-of-control psychiatric diagnosis, DSM-5, big
pharma, and the medicalization of ordinary life. New
York, NY: Harper Collins.
Reis, R. K., Fiellin, D. A., Miller, S. C., & Saitz, R. (Eds.).
(2014). The ASAM principles of addiction medicine (5th
ed.). Philadelphia, PA: Wolters Kluwer.
Shaffer, H. J. (Ed.). (2012). APA addiction syndrome
handbook. Washington, DC: American Psychological
Association.
Continued from page 23
Questions to Consider
Q How do you view your own
well-being and behaviors that
contribute to the different
domains of your life?
Q What is one area to improve
and how can you do this?
Bolier, L., Haverman, M., Westerhof, G. J., Riper, H.,
Smit, F., & Bohlmeijer, E. (2013). Positive psychology
interventions: A meta-analysis of randomized controlled studies. BMC Public Health, 13, 119.
Emmons, R. A. (2013). Gratitude works! A twenty-one
day program for creating emotional prosperity. San
Francisco, CA: Jossey-Bass.
Fredrickson, B. L. (2013). Love 2.0: How our supreme
emotion affects everything we feel, think, do, and
become. New York, NY: Plume.
Q How can you sustain your
motivation so that this
improvement lasts? c
Fox, J. (2012). The economics of well-being. Harvard
Business Review. Retrieved from https://hbr.
org/2012/01/the-economics-of-well-being
About the Author
Hibbard, J. H., & Greene, J. (2013). What the evidence shows about patient activation: Better health
outcomes and care experiences; Fewer data on
costs. Health Affairs, 32(2), 207–14.
Dennis C. Daley, PhD, served
for fourteen years as the chief of
Addiction Medicine Services
(AMS) at Western Psychiatric
Institute and Clinic (WPIC) of
the University of Pittsburgh
School of Medicine. Dr. Daley has been with WPIC
since 1986 and previously served as director of
Family Studies and Social Work. He is currently
involved in clinical care, teaching, and research.
Huffington, A. (2014). Thrive: The third metric to redefining success and creating a life of well-being,
wisdom, and wonder. New York, NY: Harmony.
National Wellness Institute (NWI). (2017). The six
dimensions of wellness. Retrieved from http://www.
nationalwellness.org/?page=Six_Dimensions.
References
Ratey, J. J., & Hagerman, E. (2013). Spark: The revolutionary new science of exercise and the brain. New
York, NY: Little, Brown, and Company.
Anderson, N. B., & Anderson, P. E. (2003). Emotional
longevity: What really determines how long you live.
New York, NY: Viking.
Seligman, M. E. P. (2012). Flourish: A visionary new
understanding of happiness and well-being. New
York, NY: Atria Books.
www.counselormagazine.com
25
ASK THE LIFEQUAKE DOCTOR
Ask the LifeQuake Doctor
Toni Galardi, PhD
Dear Dr. Galardi,
I’m a therapist who has been working at a treatment facility for about a
year, although I’ve been in the treatment field for many years. I’m in my
mid-sixties and want to retire, but I
can’t for economic reasons. I come
home at night absolutely drained and
depressed. I’m not eating very healthy
because I’m always on the run.
I haven’t been in a relationship in
many years either and I live alone. I
spend a lot of time alone and would
like to get involved with someone and
have a bigger social life. I feel stuck
and I don’t know what to do about it.
I’ve tried seeing a therapist and I felt
it was useless. I’m reaching out to you
as a last ditch effort to get out of this
rut I’m in.
Help, Dr. Toni!
– Recovery Shrink
Dear Reader,
Okay, as my approach is always body,
mind, and spirit, let us start with your
body. One way of getting more social is
to find an activity you love to do that gets
your body moving, like dancing. There
are lots of older men who take dance
classes after they retire. The key is to
take some kind of action. If you do not
like dancing, look at the list of meet-ups
in your area and see if there is something
that interests you.
Secondly, I would start preparing an
organic, high-protein salad at night before
bed so you have something to eat during
the day that is instantly available. I would
also suggest researching green drinks
that are full of chlorophyll and minerals
to energize you during the day. Drink it in
the morning and then at mid-afternoon
when you have a drop in energy.
When you get home at night, take a
shower and cleanse your body of the
day. While you are in the shower, set an
intention for releasing anyone or anything that has attached itself to your
etheric body. We take on our clients’ energies without knowing it and they act
like parasites if we do not release them
from our energy fields.
On this subject, I would also suggest
that before each client, you surround
yourself in light and hold as an intention
that only love comes into your energy
field and only love goes out of it. After
each client leaves, simply say, “I release
you from my field back to yourself, now.”
If you are still feeling discontent about
your job, write down the last five jobs you
have had and what you loved about them.
Really get into the feeling of it when you
describe the work you did. Then take the
elements of what you love to do and put
an intention out to the world every night
before bed to create a job that has the
elements of what you have done in one
position that you would love to do that
would not drain you.
For example, if your current job involves a lot of paperwork documentation and you hate that, put in your vision
that this job requires very little of it or
none of it. If what you really want is to
stop working and retire with a mate, envision that happening. Just make it as
emotionally joyous as possible.
The key is to bring into your life as
many joyous experiences as possible
to either enhance what you are already
doing or to manifest something new.
Dear Dr. Toni,
Can you recommend something I can
do for work that uses my education and
training as a therapist that doesn’t require counseling? I’m in burnout. I’ve
been working in the addiction field for
too long and need a change.
– Jan M.
Dear Jan,
You do not mention what other qualifcations you have, so I do not have
much to go on, but here are a few: college professor, organizational consultant, matchmaker for a dating service,
self-help book author, workshop leader,
professional speaker, and sometimes
they hire people with your credentials in
human resources at various companies.
If you are entrepreneurial, then a
coaching practice might be less heavy
than working with addicts in the throes
of detox. If you were to take a coaching
program that includes teaching you how
to market yourself, this is another option.
If you could get sponsors to support it,
another option is radio or Internet talk
show host. By the way, I have done most
of these things with the same education
and license. Be adventurous! c
26
Counselor | June 2017
Congruence as Self-Care:
Practicing What
We Preach
Ryan Thomas Neace, MA, LPC, &
Jeffrey A. Kottler, PhD
CONGRUENCE AS SELF-CARE
T
he subject of self-care for counselors is
one that receives plenty of attention in
the literature, as well as during conversations in the classroom, staff rooms, supervision, and the dialogues inside our heads. It
has been evident since the earliest days of
our profession that counselors and therapists must be clear-headed, as well as relatively free of distractions and pressing personal issues, in order to do our best work.
And yet, in spite of all the attention on this
subject, self-care remains one of the most
critical and pressing issues. Even among socalled experts on the subject, there is a certain amount of hypocrisy and failure to practice what is preached.
Self-Care, Self-Neglect, and Hypocrisy
Let’s begin by talking about illusional (or delusional) selfcare. I’m (Jeffrey) someone who has made a living these many
decades by talking, writing, and preaching about the importance of counselors taking care of themselves. I’ve written several books on the subject (Kottler, 2001, 2010, 2011, 2015). I’ve
delivered innumerable keynote speeches on the topic of counselor self-efficacy. One of my strongest beliefs is that who we
are is just as important as what we do. And the more strongly
and passionately we fortify ourselves, the more effectively we
can help and heal others. This is not only because such clarity and personal mastery leads to more accurate diagnostic
impressions and less likelihood of mistakes, biases, and miscues in sessions, but also because we become models for our
clients to emulate. We demonstrate, in all kinds of ways, the
importance of practicing what we preach, employing selftalk during times of crisis or stress, following healthy lifestyle
regimens, and treating others with compassion, respect, and
caring—even when we aren’t on duty. Furthermore, I’ve always
considered those among us who don’t do so to be hypocrites.
So it’s with a certain amount of shame and reluctance that
I confess that during the months that we’ve been working on
this article, I’ve clearly failed to live up to my most cherished
ideals and expectations. I’m an expert on depression, and yet
for quite some time I’ve been helplessly depressed. Even worse,
I failed to recognize what was going on. My despair, and its
corresponding neglect, began with a series of disappointments
that occurred at work and in other areas of my life. I began to
feel sorry for myself. I became lethargic and listless. I saw little
hope for my future, feeling that my age and stage in my career
now rendered me obsolete. I felt invisible and confirmed this
belief in a multitude of ways. I was even bored with myself. And
28
Counselor | June 2017
then, all of a sudden, I found myself “retired” from a job and
a charity that defined my very identity. My closest friend was
dying of cancer and I began to notice symptoms that I must be
dying as well. I lost my appetite and my weight plummeted. I
was sleeping twelve to fourteen hours each night. I consulted
physicians and they could find nothing wrong in blood tests.
Yet I was certain I had some lingering infection from my trauma
work in Nepal during and after the earthquakes, or perhaps
malaria from my work in remote jungle areas.
And then the election hit. It wasn’t only the outcome that
I found disconcerting, but also the discourse and disrespect
that had now become normative and viral. Many of my students and clients who are Latino/Latina, some undocumented,
as well as my Muslim students, were despairing and feeling
hopeless about the future. These feelings became contagious
and I felt even more “sick.” Self-care was out of the question
during a time when I found it difficult just to crawl out of bed.
On Thanksgiving evening I hit bottom. After cooking a
feast for my family and guests, we sat down at the table to
celebrate and eat when I started to feel nauseated and dizzy.
I announced to those in attendance that I didn’t feel well and
went to bed, sleeping for fourteen hours. I was now despondent and convinced I was dying.
The next morning I made myself get dressed because I’d long
ago committed to do a workshop with refugee case workers.
These are the individuals—most of whom were refugees from
Africa, the Middle East, Eastern Europe, and Asia—who had
been hired to greet new refugees and help them get settled in
their new country. They were the ones who retrieve new immigrants at the airport, find jobs and homes for them, and
situate their children in school. I found them to be among
the most courageous, important people in our country, especially during these turbulent times of the “new world order.”
And that’s exactly what I told them—how much I appreciated their challenging work, how much I wanted to honor their
contributions, how much I wanted them to know they were
appreciated, even if they often felt so marginalized themselves.
I felt tears running down my cheeks as I spoke to them. I told
them that they were my teachers and I wanted to learn from
them; I wanted to join them in their efforts. All of a sudden,
I realized that in caring for them, I was caring for myself. My
work felt meaningful again. I felt like I was once again making
a difference. I could feel energy return to my body. I could hear
passion in my voice. I started to feel more like myself again.
After the workshop was over, the participants invited me
out for a meal at an Afghani restaurant run by refugees. As
we entered the place, I realized that “authentic” didn’t quite
capture the mood; I was the only Caucasian present and everyone was eating with their hands. Goat meat, and other
things that I didn’t wish to inquire about, were put in front of
me, and for the first time in months I was starving! I ate three
helpings of everything, and ever since then I was cured. My
appetite returned, my sleep cycle normalized, I gained some
weight back, and the cloud hovering over me slowly dissipated. I was left to reflect on the reality that although I very likely
did suffer from some lingering health issues, it was depression
that had inhabited me. I didn’t recognize it because I’d never
been depressed before—at least since adolescence. And then
CONGRUENCE AS SELF-CARE
I remembered that I had this article to
write with Ryan and wondered whether I
still felt qualified to contribute to it given
my own self-neglect.
It was that feeling of hypocrisy that
partially motivated me to get back into
my rigorous athletic pursuits and exercise
regimen. I changed my diet. Rather than
complaining about how my clothes no
longer fit now that my body was permanently smaller, I gave away most of my old
clothes and began again. It felt like, even
at my advanced age, I was starting over. I
would relocate to be closer to my granddaughters. I would find ways to continue
my work with refugees. I would reinvent
myself and launch a whole new chapter
of my life. After all, isn’t that what we try
to do with our own clients?
Living with Uncertainty,
Self-Doubt, and Imperfection
Jeffrey’s story is important at the
outset, if for no other reason than he is
hardly alone in his experience—not by a
large margin (Skovholt, 2000; Skovholt,
Grier, & Hanson, 2001). Indeed, Sapienza
and Bugental (2000) remark that most
of us counselors have never been prepared for the critical life mission of
taking care of ourselves since our jobs
are so focused on caring for others. And
even when clinicians are encouraged to
practice self-compassion, Norcross and
Barnett (2008) point out that most of us
are so busy hustling and multitasking,
trying to help clients, keep practices
afloat, and take care of families that
there is precious little time left over to
focus on ourselves. During those rare
instances when we might take opportunities to nourish ourselves, this behavior may be viewed as self-indulgent. It
is clear that self-care is just not considered much of a priority; even so, many
among us feel disillusioned and hypocritical for our inability (or unwillingness)
to live up to even minimal standards
of self-care (Penzer, 1984). Several decades ago, Pope, Tabachnick, and KeithSpiegel (1987) reported that 60 percent
of counselors surveyed admitted that
they continue to see clients even when
they believe themselves to be too distressed to be effective. This is consistent
with a more recent study conducted by
the American Counseling Association
(2010) that revealed a similar number
of us continued practicing during times
when we felt impaired.
Such data is even more disturbing
when we consider what it is that we actually do with clients, how we primarily
use ourselves as an instrument of diagnosis and treatment. It is through the
clarity and stability of our own personal
functioning that we work to establish and
maintain meaningful connections with
our clients free of biases, distortions, and
self-indulgence. Yet, no matter how fully
functioning we might feel during the best
of times, there are still instances when we
are triggered, grieving some loss, lapsing
into personal issues or even responding
impulsively or inappropriately. Consider
the much greater impact when we walk
into a session depressed, highly anxious,
disappointed or otherwise preoccupied.
It is often assumed that counselors
are drawn to the profession because we
are incredibly adept at relating to others
while at the same time being experts who
have something significant to contribute
to deep, vexing, and hitherto unresolvable practical, mental, emotional, existential, and even spiritual questions. In
other words, we are expected to have a
certain degree of finesse, and to have it
all together, sometimes even close to perfection in personal functioning. We reinforce this image with the presentation of
ourselves as almost always calm, unflappable, and in control; we seem to have an
answer for everything—and even when
we do not, we act like this is completely
acceptable and appropriate. Clients have
no idea that inside our hearts and minds
we are sometimes churning with selfdoubt, confusion, disorientation, and a
sense of helplessness. Disturbing questions are constantly popping up:
Q “What does this client really mean
by that?”
Q “Why am I still unable to figure out
what is going on?”
Q “Did I just miss something
important?”
Q “Why did I just say that? Now what
should I do?”
Q “Is it noticeable that I have no clue
what is going on right now?”
Of course we cannot exactly admit that
we are distracted or confused some of the
time, so we must live with a certain degree
of deception in which we are used to pretending to know and understand more
than we really do. Of course that eventually takes a toll on our psyche, given
how infrequently we are permitted the
option of taking a “sick day” (or month).
Sometimes our personal motives for
becoming counselors in the first place
may also get in the way, tending to organize around common themes that
are often unconscious and unaddressed
within clinical supervision (Adams, 2013;
Sussman, 2007). The themes often involve
lingering struggles from childhood loss
and ongoing needs for recognition and
approval (Barnett, 2007; Kuchuck, 2013),
as well as trying to clarify and bring resolution to our own problems (Orlinsky &
Ronnestad, 2004). There is also a recurrent theme related to learning greater
authenticity as well as feeling a greater
sense of power and control over both
others and ourselves (Hamman, 2001).
Although there are certain advantages to presenting ourselves as models
of personal effectiveness in order to intensify our power and influence in sessions, there are also certain side effects
that get in our way, especially when we
start to believe in our own omnipotence.
As it turns out, being honest and clear
about our failures, mistakes, and imperfections is one of the most important
attributes to improve our personal and
professional functioning in a multitude
of areas. Likewise, it is just as important
that we have a clear sense of how our appearance, comportment, and behavior
conveys to others the image of the consummate professional.
The other day I (Ryan) was making a
house-call for a client who had recently
been in a car accident and was unable to
walk. At one point in the session, I was
delighted when his wife stuck her head
in the door and said hello. During this
brief interaction with her, she mentioned
that her own counseling was going well.
Since I am always looking for good referral sources, I asked who she was seeing.
In telling me the counselor’s name, she
also mentioned that this professional was
always dressed meticulously and really
seemed to have her stuff together. Not
missing a beat, my own client chimed in
and said, “I know—this guy is the same
way,” referring to me and my own style
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29
CONGRUENCE AS SELF-CARE
of dress and approach. I explained that
the way I carried myself was an effort to
help them “buy me” and believe that I
could help.
That was true to some degree, but the
deeper truth is that while the veneer of
mystique may be enough to get clients
in the door and through the first few sessions, it is not nearly enough to go the distance with them, especially if it is in fact
just spit-and-polish. After all, something
like half of all clients terminate counseling before they achieve any real or tangible benefits (Teyber & Teyber, 2010).
Ultimately, clients need and deserve
counselors who are people of depth, capable of seeing beyond the superficial
insights and advice—given that has already been offered to them by their family
members, coaches, pastors, bosses, and
others before they ended up on our doorsteps. They need counselors who are selfpossessed enough to have the capacity to
sit with them through difficult and sometimes painful work (Ghent, 1990). There are
often times when we are indeed confused
and overwhelmed, when we do not know
what to say or do or how to circumvent or
remove the obstacles obstructing their desired path. We may try to pretend that we
are all-knowing and all-powerful, but at
our core we must also live with ourselves
as flawed, imperfect beings who are struggling just like everyone else.
Toward Congruence
In his quintessential essay, “The
Necessary and Sufficient Conditions
of Therapeutic Personality Change,”
Rogers (1957) introduced the concept of
“congruence,” which he defined mostly
negatively, talking far more about what
congruence wasn’t rather than what it
was. For Rogers, incongruence initially
referred “to a discrepancy between the
actual experience of the organism and
the self-picture of the individual insofar
as it represents that experience” (1957, p.
96). Therefore, individuals were considered congruent when their actual experiences were in line with their self-image.
But this definition is insufficient in
many ways, and as he honed his conceptual framework, Rogers (1961) broadened
congruence into a deeper, richer experience, and one that was not so locked-in to
one conceptual perspective. Throughout
most of his life, Rogers sought to research
30
Counselor | June 2017
and describe ideas and practices that
might be useful to practitioners regardless of their particular approach and orientation. Gendlin (1967) further explored
the concept of “realness” as a central fixture of congruence, extending it beyond
a subjective inner experience on the part
of the counselor and outward toward
the client. Being real and congruent in
this sense naturally means beginning to
remove the cloaks of power and authority which are implicit to our vocation as
aforementioned. Gendlin believed that
counselors need not necessarily present
themselves as figures of perfection, as
always wise and strong, since it is precisely our own vulnerabilities and limitations that make us more accessible
and relatable. “I find that, on occasion,”
Gendlin admits, “I can be quite visibly
stupid, have done the wrong thing, made
a fool of myself. I can let these sides of
me be visible when they have occurred
in the interaction” (1967, p. 121).
In short, for our
purposes, congruence
is simply being
ourselves—all of
ourselves—well-timed
and with clients’ best
interests at heart,
because we cannot be
anything other than
who we are anyhow.
Even half a century after these contributions, many of us still tend to present
ourselves as models of perfection even if
this means we live with incongruence, inauthenticity, and to some extent, a degree
of hypocrisy when we cannot practice in
our lives what we advocate for others. This
moves counselors in the opposite direction from what Rogers and Gendlin first
proposed, setting us up as experts who
always know what is best and are usually
infallible (Gendlin, 1967; Rogers, 1957).
Bohart (2015) believes that this causes
us to “dice” our clients into pieces that
we can manage or control, rather than
experiencing the whole of them and our
work together, which is much more overwhelming and difficult to wrap our arms
around. In so doing, we naturally limit
our ability to see clearly the rest of the
pieces that compose our clients’ lives and
experiences. When we hold such a fragmented view of others, this can lead to a
similarly fragmented view of ourselves.
Limiting what we are willing look at in
our clients and pretending that we have
counseling all figured out is precisely the
same kind of philosophy at work when
we limit what we are willing to look at in
ourselves and pretend that we have our
lives all figured out.
This kind of indictment of modern-day
counseling resonates deeply with many of
us on some level, but we just cannot help
but hide all of our own struggles—we find
ourselves loathe to admit struggle or to
challenge the dominant narratives which
seem to present counseling as an exact
science, each intervention empirically
supported and every approach evidencebased. At conferences and workshops, not
to mention in our professional training, we
are often led to believe that even though
it is certainly desirable and commendable to select and employ scientifically
validated strategies and interventions,
most of the time we are operating based
on what feels right in the moment. Given
that at times counselors’ “feelings” may
very well be distorted, exaggerated, and
polluted by their own unresolved issues,
this can indeed place clients at risk.
Bearse, McMinn, Seegobin, and Free
(2013) found that social stigma, anticipated risks, and fear of self-disclosure all contribute to our tendencies to minimize our
personal issues, ignore our own needs,
and pretend we are invincible. Even our
colloquialisms betray the climb back into
the power seat. Counselors often say
things like, “We can’t transmit what we
don’t have” (actually a paraphrase from
the Big Book of Alcoholics Anonymous,
1939) to indicate their awareness of the
need for self-care and growth, but this
kind of sentiment actually returns us to
the place of presumption, of Bohart’s
(2015) interventionist philosophy, where
counseling is a process by which those
who have much (presumed to be counselors) give to those who have little or
nothing (presumed to be clients).
CONGRUENCE AS SELF-CARE
What is more accurate and consistent
with reality is to say that we cannot help
people when we are not operating genuinely from the core of who we are. This
does not mean, as Gendlin (1967) and
others have pointed out, that we must
have it all together, but that we humbly
acknowledge to ourselves, and sometimes, cautiously and appropriately for
their benefit, to our clients, that we are
struggling. This means we must come to
terms with the struggle itself. Working our
struggles through to resolution is even
better, but it is not really the resolution
that counts—we know that life is full of
core issues which refuse to allow us to
tie a neat ribbon of finality around them.
In short, for our purposes, congruence is simply being ourselves—all of ourselves—well-timed and with clients’ best
interests at heart, because we cannot be
anything other than who we are anyhow.
And research seems to indicate that who
we are is ultimately, if not immediately,
vitally important to the process side of
counseling. Our willingness to be who we
really are, and to operate from that core
without shame or hiding, is the clarion call
to counselors everywhere. Even as clients
ask, “Will you see me? Will you accept me
for all my struggles and all my successes
alike?” we must ask the same of ourselves
about ourselves. Congruence, meaning
being and acting as ourselves in counseling, is the ultimate form of self-care.
There is No Shortage of Advice
Considering all the research, articles,
and books reporting that we do not adequately take care of ourselves, there is
certainly no shortage of literature telling
us how to do it best. Perhaps unsurprisingly, the suggestions range somewhat
broadly in terms of approach, technique,
theory, duration, frequency, and concreteness. For example, Bradley, Whisenhunt,
Adamson, and Kress (2013) suggest that
creativity is paramount to effective counselor self-care, envisioning each of us as
a plant, observing the color of our leaves,
having access to sunlight, and being fed
with nourishment. Another conceptualization of counselor self-care literature
in recent years is based on mindfulness.
Shapiro, Brown, and Biegel (2007) found
that a cohort-design, mindfulness-based,
stress-reduction program reduced counselor stress, negative affect, rumination, and
both state and trait anxiety. Christopher,
Christopher, Dunnagan, and Schure (2006)
reported positive changes in counselor
trainees’ stress levels after providing a
course that integrated mindfulness with
yoga and meditation. Similar gains were
reported with interventions in other studies (Newsome, Christopher, Dahlen, &
Christopher, 2006; Christopher & Maris,
2010). Based on their mostly positive outcomes, Boellinghaus, Jones, and Hutton
(2013) also recommend the use of mindfulness loving-kindness meditations as
an approach for increasing counselor selfcare and compassion. Along with mindfulness, Dattilio (2015) suggests a range
of options derived from our therapeutic
work itself: CBT self-emotion scanning
and self-cognitive distortion monitoring,
positive thought statements, ACT-based
nonattachment and compassionate selfobservation, and finally, a series of pointed
questions for evaluation, including items
like, “Have there been any comments from
others about their observations of me,
specifically as it relates to family members, friends or colleagues?” and “Have
you noticed any differing reactions from
others who know you well?”
Some of these sources barely scratch
the surface of the available material at our
disposal. It is not like there is a dearth of
techniques and strategies for self-care;
there are even workbooks completely
devoted to the subject for counselors
(Kottler, 2011). Yet, as valuable as such
structures and advice may be to organize self-care efforts in a meaningful and
strategic way, the main impediment to
consistent action isn’t a lack of options,
but rather sustained behavior over time.
This is no less true with respect to our
clients who have little trouble getting
started with their own self-care programs,
whether they involve exercise, lifestyle
adjustments, relational connections (or
disconnections) or self-talk; the greatest
challenge involves maintaining those
efforts over time such that they become
part of daily functioning without exception. Most people, and perhaps especially
therapists, tend to respond better to general principles of self-care than they do
any specific techniques or prescriptions
(Norcross, 2000).
In other words, there have been so
many such articles and books published
in the literature, all of which preach
similar themes, and perhaps present
the latest and greatest program, but
ultimately self-care is about an attitude, a cherished belief that we can
only do our best work taking care of
others when we also take care of ourselves. And we take care of ourselves
most fully when we work from the core
of who we really are, when the whole
of us is in plain view rather than just
the parts we think are acceptable. This
not only leads to greater clarity and
effectiveness in our sessions, but also
demonstrates to clients that we live
exactly the same principles and ideas
that we are teaching to them. This includes, at appropriate times, presenting ourselves as imperfect and flawed
individuals, but also absolutely committed to our own growth, learning,
and improvement. c
About the Authors
Ryan Thomas Neace, MA, LPC, is a
clinical mental health counselor
with fifteen years of mental health
experience. He is the founder and
director of Change, Inc. in St. Louis,
MO, where he is pursuing a PhD in
counselor education at the
University of Missouri, St. Louis. Ryan resides in St.
Louis with his wife, two children, and three cats.
Jeffrey A. Kottler, PhD, is the author
of over ninety books about a wide
range of topics related to counseling, education, and psychological
phenomena. Some of his best
known and recent works include On
Being a Master Therapist and
Change: What Really Leads to
Lasting Personal Transformation. Dr. Kottler is professor emeritus of counseling at California State
University, Fullerton and clinical professor at Baylor
Medical College in Houston, where he resides.
References
Adams, M. (2013). The myth of the untroubled therapist:
Private life, professional practice. New York, NY:
Routledge.
Alcoholics Anonymous. (1939). Alcoholics Anonymous.
New York, NY: Alcoholics Anonymous World Services.
American Counseling Association (ACA). (2010).
American Counseling Association’s task-force on counselor wellness and impairment. Retrieved from http://www.
creating-joy.com/taskforce/tf_history.htm
Barnett, M. (2007). What brings you here? An exploration of the unconscious motivations of those who choose
to train and work as psychocounselors and counselors.
Psychodynamic Practice, 13(3), 257–74.
Bearse, J. L., McMinn, M. R., Seegobin, W., & Free, K.
(2013). Barriers to psychologists seeking mental health
care. Professional Psychology: Research and Practice,
44(3), 150–7.
Bohart, A. C. (2015). From there and back again. Journal
of Clinical Psychology, 71(11), 1060–9.
Continued on page 41
www.counselormagazine.com
31
Addiction
Counselors
in the
Compassion
Fatigue Cycle
Kathie T. Erwin, EdD, LMHC, NCC, NCGC
I
n Greek mythology, King Sisyphus was
condemned to roll a huge boulder up a
steep hill with only a moment of satisfaction before it rolled down the hill and he
trudged back to repeat this endless cycle.
Counselors who are committed to helping
clients with addiction can understand
Sisyphus’s struggle. As these counselors
work diligently session after session to impart hope and come alongside clients in the
early stages of counseling, there are moments of wonder in which the top of the hill
seems achievable. With success in sight, the
lure of the addiction becomes more powerful than the struggle and the “rock” rolls
down the hill again. Dealing with this cycle
of ups and downs in addiction treatment can
take a toll on even experienced counselors.
Some attempt to deny it, others mask the
disappointments in harmful ways or assume
a cloak of invincibility, but all are at risk for
compassion fatigue. Borrowing phrases from
Albert Camus’s essay The Myth of Sisyphus
(1942), let’s explore the rocky road into and
out of compassion fatigue.
Overcome by “Futile and Hopeless Labor”
Clients living with addiction may feel abandoned, alone,
and discouraged as their addiction separates them from family
and friends. The acceptance and compassion shown to them
by addiction counselors is crucial for building therapeutic
trust and a bridge to hope. However, as Dr. Charles Figley
(1995) identified twenty years ago, the cost of sustained compassion and ongoing exposure to clients’ suffering can lead
to secondary traumatization, which later became known as
“compassion fatigue,” a serious concern for counselors and
other first responders. Yet there almost seems to be a conflict inherent in this condition since the nature of counseling
is to actively listen to the details of suffering, trauma, fear,
and despair. Some clients tell their stories in such a vivid
manner that counselors can feel captured by the descriptions
and unable to shake the emotional impact. What escalates
the stress to a higher level, according to Figley (2002a), is
when it reaches “a state of tension and preoccupation with
COMPASSION FATIGUE
traumatized patients by reexperiencing the traumatic events,
avoidance/numbing of reminders, and persistent arousal associated with the patient” (p. 1435).
Compassion fatigue is more than burnout, more than frustration with charting treatment notes, and more than feeling underpaid and overworked, yet it can be complicated by
some or all of these frustrations. “Burnout” is a catchphrase
from the past millennium that persists as a sociological phenomenon which glorifies a multitasking, fast-paced existence.
However, years earlier Pines and Maslach (1978) recognized
how this overload can adversely affect counselors and social
workers years before it became trendy. Figley’s (2002b) work
in developing treatments further clarified the significant differences between burnout and compassion fatigue as they affect
mental health professionals who work with traumatized clients.
Compassion fatigue is not confined to counselors who work on
the front lines of a disaster or in other settings with traumatized
clients. The nature of vicarious or secondary traumatization is
not linked to a place, a situation or any direct proximity to the
trauma incident. Thus it can catch counselors by surprise to be
catapulted into an almost imperceptible moment of transference when clients’ traumatic experiences cross over into the
psyche of counselors. That point of emotional contact can be
difficult to identify, but the residual impact is noticeable first
in small ways that gradually become overwhelming.
Keep in mind that some counselors choose to specialize in
addiction counseling as a way to “pay it forward” for their own
recovery experiences. However, listening to stories of traumatic
incidents connected with addictive behaviors can trigger traumatic memories from their own addiction histories. And thus
the boulder that was secured at the top of the mountain begins
to slowly and steadily roll downward . . . how far will it fall?
How hard will it be to roll back the boulder while maintaining enough fortitude to help clients roll back their boulders?
When does the struggle become too much?
Annie Fahy (2007) writes about compassion fatigue among
substance abuse counselors with an insider’s perspective,
daring to say what others silently bemoan in her insightful
article, “The Unbearable Fatigue of Compassion: Notes from
a Substance Abuse Counselor who Dreams of Working at
Starbucks.” Along with the difficulties of working in budgetstrained treatment programs and with increasingly difficult
clients, Fahy (2007) points to the unseen burden of counselors’ role confusions and mixed expectations to “straddle the
high wire of therapeutic relationship, behavior monitor, and
report to the judge” (p. 200). Fahy (2007) notes another less
obvious issue exists because “most substance abuse workers
believe that stabilization of substance abuse actually brings
up more symptoms if the substance was used to numb PTSD
symptoms. Abstinence may actually exacerbate symptoms
and create another kind of coping crisis” (p. 201). Following
the long tradition of developing autobiographies as part of
the treatment, clients read and discuss these past incidents
in individual and group counseling. Fahy (2007) suggests that
this emphasis on “truth telling” has “a high potential to elicit
trauma material” (p. 202). While the attention may be given to
how this affects clients, less attention is paid to how repeated
exposure to these detailed stories affects counselors.
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33
COMPASSION FATIGUE
The Conscious Hero’s Awareness
At some point, Sisyphus had to realize that the stone was not going to stay
on the mountain. Yet he went back to
the valley, fully conscious of what would
happen again and again. With the same
persistence, addiction counselors shake
off yesterday’s frustrations and client
disappointments to press ahead for the
next day. Those who are able to continue
in this field and maintain their emotional well-being must become “conscious
heroes.” Compassion fatigue does not
have to sideline capable counselors or
cause them to leave the field where their
expertise is desperately needed. The
real heroes are those who admit their
limitations and seek support for emotional overload.
At what point does the burden of counseling become compassion fatigue? The
symptoms of this secondary traumatization are similar to those seen in clients.
To place these in a context of the counseling relationship, these are symptoms
of concern that are early warning signs
of compassion fatigue:
Q Persistent intrusion of client stories
and emotions into one’s thought
processes and feelings
Q Client stories have become triggers
for one’s past trauma memories
Q Unexplained emotional changes
such as low frustration tolerance,
sarcasm, anger or rage
Q Attempts to avoid certain clients
without explaining the reason to
supervisors
Q Hyperarousal, even when situations do not warrant vigilance
Q Taking out work frustrations on
one’s partner, children, family or
friends
Q Inability to emotionally leave work
at the office
Q Casting blame on self or others in a
depreciating manner
Q Increasing of self-medication,
whether with substances, exercise,
food, smoking, prescription drugs
or other external sources
Q Isolating with solitary hours of television or Internet gaming
Q Negative attitude toward potential
34
Counselor | June 2017
efficacy of counseling and/or one’s
ability to effectively counsel
Q No longer able to distinguish transference and countertransference
with clients
Q Unwillingness to discuss these concerns with a supervisor or seek outside supervision and/or counseling
Compassion fatigue
does not have to
sideline capable
counselors or cause
WKHPWROHDYHWKHèHOG
where their expertise is
desperately needed.
The presence of any of these compassion fatigue symptoms is cause for concern. When counselors fail to recognize
the symptoms leading to compassion
fatigue, colleagues or supervisors must
confront these counselors in a proactive
manner. Evaluating the impact of compassion fatigue also involves breaking
through the denial. Often the first response is to deny, minimize, and become
angry at being confronted with these
symptoms. In some work situations, such
as a hospital or treatment program, admitting to the symptoms may mean being
relieved of counseling duties for a time.
That can leave a financial impact as well
as concern about professional reputation.
It can feel like these counselors are being
singled out as ineffective. Hippocrates
cautioned a physician to “heal thyself,”
but that can be a difficult message to hear.
The conscious heroes are the counselors
who can take in that message and recognize that it is a blessing, not a curse,
for helpers to receive help.
So in which work settings are addiction counselors most likely to fall victim
to compassion fatigue? There is no single
place where this can happen. Lent and
Schwartz (2012) suggest that counselors
working in community mental health are
substantially more at risk than counselors working in private practice or within
an inpatient treatment program. A look
at several other studies seems to suggest
that the workplace is not in and of itself a
breeding ground for compassion fatigue.
However, receiving emotional support
and social connectedness from counselors and supervisors in the workplace was
an important factor in sustaining counselor well-being (Ducharme, Knudsen,
& Roman, 2008). Because it is so important to have coworkers who can see and
are willing to compassionately confront
their fellow counselors who are on the
slippery slope to compassion fatigue,
such a collaborative environment can
become a protective factor for everyone.
There is no shame in acknowledging
the need for support. Addiction counselors who have worked many years in the
field and insist that there has been no
emotional toll, physical stress or sleepless nights are most likely not acknowledging the reality of human limitations in
this complex work. How many times have
we heard about the “wounded healer”?
To shrug that off as “someone else, not
me” is to remain wounded and a less capable healer. The conscious heroes have
taken a share of wounds, stepped away
to heal, and come back stronger. If that
were not the case, how could Sisyphus
have the strength to roll the rock back
up the hill again?
The Absurd Hero’s Passion
Sisyphus made his share of mistakes,
yet he was passionate about life. Addiction
counselors have their own stories about
the ups and downs of life, yet they remain
passionately committed to helping their
clients. Even in the face of relapses and
therapeutic dropouts, addiction counselors have to cling to the belief that all
clients have the potential to move past
immediate obstacles and reconnect with
their true selves.
For families trapped in the addictive
cycle, the optimism of counselors surely
seems absurd. For counselors in other
psychotherapeutic specialties where
success stories occur more frequently,
addiction counseling seems absurd.
Looking at the counseling process from
a lens of burnout, addiction counselors
have to decide whether there is enough
inner strength and courage to fulfill the
role of absurd heroes.
Part of accepting the absurdity of
the counselor’s role is to lay down the
COMPASSION FATIGUE
mantle of invincibility. Knowing theories and techniques is like possessing a
collection of brushes and paints. Unless
these tools are in the hands of an artist,
no amount of rote actions will produce
a masterpiece. The same is true with
models, diagrams, and multistep approaches to counseling. These are useful
tools, but only in the hands of passionate, creative, and sensitive counselors.
One aspect of compassion fatigue can
occur when counselors are constrained
by a treatment plan or agency policy that
works in a one-size-fits-all approach,
removing their ability to respond to the
unique needs of each client. Removing
that sense of the artistry of counseling
can make this deeply personal process
become stagnant and repetitious.
One aspect of
compassion fatigue can
occur when counselors
are constrained by a
treatment plan or
agency policy that
ZRUNVLQDRQHVL]HèWV
all approach, removing
their ability to respond
to the unique needs of
each client.
Fahy (2007) advocates the renewed view
of substance abuse treatment models both
for the benefit of clients as well as preventing burnout and reducing conditions
for compassion fatigue among addiction
counselors. Among the treatment options
that Fahy (2007) supports for addiction
counseling are the trauma recovery and
empowerment model (TREM), motivational interviewing (MI), and narrative
therapy (NT). The TREM model uses group
therapy based on psychoeducation and
personal skill development with emphasis on finding alternative, healthy ways
to cope with stress and triggers. MI and
NT are client-focused, individualized approaches that take the power from total
control of addiction counselors and continually bolsters clients’ ability to take back
personal power in constructive ways.
Fahy (2007) suggests that these “may have
benefit to counselors dealing with trauma
and the complexities of active substance
use” (p. 203). As more client-centered
approaches become popular, there is a
shift of power from prior models of therapeutic relationships between addiction
counselors and clients.
Perhaps Fahy is one of the absurd
heroes who is willing to set out in new
directions that may be a better fit for the
upcoming generation of substance abuse
clients and counselors.
Becoming Stronger than the Rock
Camus reflects on Sisyphus’s seemingly endless toil: “At each of those moments
when he leaves the heights and gradually sinks toward the lairs of the gods,
he is superior to his fate. He is stronger
than his rock” (1942). To overcome compassion fatigue is indeed to be “stronger
than the rock” that seeks to weigh down,
discourage, and distance addiction counselors from the calling to counsel. Let us
take up the challenge to help counseling
students and fledgling addiction counselors to recognize and seek support for
compassion fatigue. Think back to your
early career experience working with
substance abuse. The anxiety, feelings
of inadequacy, frustration with difficult
clients, shock at hearing some of clients’
traumatic experiences, and stress of an internship and studying are fertile grounds
for compassion fatigue. Yet what intern
or new counselor wants to admit to these
symptoms for fear of losing the position?
And how many supervisors show an
open-door attitude toward hearing this?
It is easier to say “next” and bring in the
next newbie than to take time to invest
in that intern. The unspoken message
is this: never admit weakness or need
in order to keep a position in this field.
Newbie or veteran, we all face the rock.
Or as the infamous line from the Pogo cartoon of yesteryear announced, “We have
met the enemy and he is us.” Failure to
acknowledge compassion fatigue is the
rock over which most counselors in addiction and trauma will stumble at some
point in the work. We also need to point
out the dangers of the rock to others at
risk such as physicians, nurses, police,
firefighters, emergency medical technicians, domestic violence shelter workers,
attorneys, crisis shelter workers, and crisis
hotline workers. How many people from
these walks of life have come through
addiction programs? How many are exposed to vicarious or secondary trauma
as well as on-scene trauma situations?
Can you see the connection?
Becoming stronger than the rock is the
triumphant side of compassion fatigue.
Addiction counselors who have become
stronger did so by first acknowledging
and dealing with weakness. Maintaining
positive self-care is key to sustaining
emotional well-being. Taking time off
for relaxation and having fun with family
and friends is as powerful an inoculation
against compassion fatigue as any medical inoculation is to fight disease. Self-care
is not just for clients; it is equally important to sustain addiction counselors. The
ability to help clients starts with hope,
and counselors must have hope to give
hope. Hope is stronger than the rock. c
About the Author
Kathie Erwin, EdD, LMHC, NCC,
NCGC, is an associate professor in
the School of Psychology and
Counseling at Regent University. Dr.
Erwin is the author of six professional books, an ethical thriller
novel, and award-winning psychological thriller screenplay. As a national certified gerontological counselor, her research interests are healthy
aging and multigenerational families.
References
Camus, A. (1942). The myth of Sisyphus. Retrieved from
http://dbanach.com/sisyphus.htm
Ducharme, L. J., Knudsen, H. K., & Roman, P. M.
(2008). Emotional exhaustion and turnover intention
in human service occupations: The protective role of
coworker support. Sociological Spectrum, 28(1), 81–104.
Fahy, A. (2007). The unbearable fatigue of compassion:
Notes from a substance abuse counselor who dreams
of working at Starbucks. Clinical Social Work Journal,
35(3), 199–205.
Figley, C. R. (1995). Compassion fatigue as secondary
traumatic stress disorder: An overview. In C. R. Figley,
(Ed.), Compassion fatigue: Coping with secondary traumatic stress disorder in those who treat the traumatized
(pp. 1–20). New York, NY: Routledge.
Figley, C. R. (2002a). Compassion fatigue:
Psychotherapists’ chronic lack of self-care. Journal of
Clinical Psychology, 58(11), 1433–41.
Figley, C. R. (Ed.). (2002b). Treating compassion fatigue.
New York, NY: Routledge.
Lent, J., & Schwartz, R. (2012). The impact of work setting, demographic characteristics, and personality factors related to burnout among professional counselors.
Journal of Mental Health Counseling, 34(4), 355–72.
Pines, A., & Maslach, C. (1978). Characteristics of staff
burnout in mental health settings. Hospital and
Community Psychiatry, 29(4), 233–7.
www.counselormagazine.com
35
A Phenomenological
Study of Stress
and Burnout
Experienced by
Licensed Alcohol
and Drug Counselors
Derrick Crim, EdD, LADC, CPPR, MAPM
STRESS AND BURNOUT
A
s a licensed alcohol and drug counselor (LADC), I have a growing conFHUQDERXWVWUHVVLQWKHèHOGRIDGGLFtion counseling. Stress not only affects
clients, as my personal experience suggests,
but also organizations. This qualitative study
examined the causes and coping strategies
associated with personal and occupational
VWUHVV H[SHULHQFHG E\ èIWHHQ /$'&V LQ D
0LGZHVWHUQ6WDWH7KHVWXG\VSHFLèFDOO\DGdresses the factors creating stress beyond
the generalized concept of “stress managePHQWÛDQGLGHQWLèHVWKHVSHFLèFVRXUFHVRI
stress to move the alcohol and drug counselLQJèHOGIRUZDUGWRDKHDOWKLHUVWDWHIRUERWK
individual counselors and organizations. The
IROORZLQJ DUH P\ FHQWUDO èQGLQJV LPSOLFDtions, and recommendations.
The Study
Participants
I adopted the phenomenological method and used a snowballing sampling technique. The fifteen participants were ethically and culturally diverse and were required to have at least
one year of counseling experience. They also may have served in
supervisor positions with previous counseling experience. The
selection incorporated a range of experience from those engaged
in the early stages of their careers to “seasoned” counselors.
Method
I used a warm-up phase to allow participants to feel comfortable and describe their professional work experience. I
then asked for specific responses about their experiences with
stress and burnout and finally asked participants to share several stories regarding “critical incidents” (Denzin & Lincoln,
2000) to capture a more complete picture of a stress experience and its impact.
Personal Stress
Money
Participants claimed that a lack of money caused them personal stress because of their inability to pay for personal expenses and costs associated with professional advancement.
Financial stress included an inadequate salary as well as a lack
of sufficient resources to pay student loans, care for loved ones,
and save for retirement. Participants also identified low salaries
and compensation for professional work as a related issue. The
inability to meet financial needs created stress. Human resource
departments should find ways to fairly compensate employees
and offer benefits such as pay raise programs, education reimbursement for college, and financial literacy classes.
The study revealed the need to address economic stress and
its implications. According to Haley and Miller (2015), economic
stresses are aspects of economic life that are potential stressors for employees and their families. It includes both objective
factors such as the inability to meet current financial needs
and subjective factors such as financial concerns and worries
(Probst, 2005). Also, economic stresses have grave implications for families of affected employees. Research shows that a
majority of Americans have inadequate knowledge about concepts related to personal finance and basic economics (Probst,
2005). A financial literacy program would focus on such topics
as budgeting, personal finance, and record-keeping. The program can be delivered to LADCs through informational seminars, pamphlets or webinars.
Caring for Others
Participants described stress stemming from caring
for primary and extended family members. This included
caring for birth or origin family members such as parents
and siblings, along with family created by birth and marriage, including spouses, children, and other relatives. Stress
created by these circumstances was actual or anticipated,
proved overwhelming, and at times left counselors feeling
alone and powerless.
The study revealed that caring for family members presents a range of emotions—often guilt, anger, and resentment
resurface as unresolved issues. Accordingly, stress stemming
from family role environment includes mental and physical
well-being outcomes. Research has shown that work-family conflicts are related to worse physical health (Bellavia &
Frone, 2005).
I recommend family support that includes flexible work
schedules, child care referrals, and leaves of absence. These
programs reduce employee work-family conflict and enhance
employee job attitudes and behaviors (Frone, 2003). Family
support programs are a means for maintaining morale and
attracting and retaining a dedicated workforce (Frone, 2003).
Aging
Aging as a cause of stress was accompanied by a variety of
physical changes, reduced capacity for performing work, and
preoccupation. Large bodies of work concerning the aging process have documented a variety of physical, cognitive, and emotional changes that accompany aging (Barnes-Farrell, 2005).
Participants suggested that these changes have the potential
to disrupt fulfilling the demands of work.
Besides the physical changes, a dichotomy between older
and younger counselors created a division between counselors and proved to be a significant cause of stress for older
counselors. The study revealed the need to understand the
functionality of older workers and its stressful impact on work
and work environment (Barnes-Farrell, 2005). For example,
ergonomic interventions aimed at redesigning work conditions, work tasks, and work tools show great promise for maintaining functioning and performance (Barnes-Farrell, 2005).
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37
STRESS AND BURNOUT
For another example, older counselors
completing required documentation
could benefit from adaptive technology
because of declining visual capabilities.
Other opportunities for redesign regarding sensory, psychomotor, and cognitive
changes with the human-computer interface are critical for older worker wellbeing (Barnes-Farrell, 2005).
The study also revealed the need to
understand conditions that create stress
for aging counselors. It has been argued
that older workers are more experienced
at using cognitive strategies to regulate
their emotions (Barnes-Farrell, 2005).
Also, Randolph (2013) suggested that
older workers learn to take advantage
of coping resources and are therefore
able to manage considerable amounts of
stress. Despite these acknowledgments,
organizations should be familiar with
conditions under which older counselors encounter difficulties in maintaining
performance levels.
I recommend professional development emphasizing the development of
new skills and increased participation,
involvement, and psychological support
for older counselors within the organization. Also, professional development
would elicit idea sharing between older
and younger counselors. Older workers
prefer experiential learning to conceptual learning approaches and enjoy using
different strategies during the learning
process (Randolph, 2013). Special attention to older counselors yields rewards
since they often hold responsible positions and may be at increased risk for
experiencing stress.
Balancing Work and Family
Demands
Counselors described stress in managing family relationships and work responsibilities. Work problems and demanding
caseloads interfered with family life. One
demand placed on counselors involved
the use of time: time spent in one role
is time that cannot be spent in another (Judge & Colquitt, 2004). Counselors
struggled to balance priorities between
work and home.
The study revealed the need to promote organizational justice by being responsive to work-family conflict. Judge
and Colquitt (2004) argued that justice
literature pertains to understanding
38
Counselor | June 2017
how family-friendly policies work. They
maintain that organizations with unfair
policies and practices contribute to the
interference of work with family life.
Thus, organizations should consider employee views and experiences regarding
work-family conflict. I recommend distributing employee surveys to provide an
accurate picture of employee needs, thus
creating procedures representative of all
group concerns (Judge & Colquitt, 2004).
Also, leaders should adopt procedures
responsive to shared concerns. Bellavia
and Frone (2005) noted that an accurate
needs analysis with organization-wide
participation serves a vital component
of responsiveness to work-family issues.
Next, I provide a summary of central
findings, implications, and recommendations for causes of “occupational”
(Ruotsalainen, Verbeek, Mariné, & Serra,
2014) or professional stress associated
with performing work as an LADC.
Occupational Stress
LADCs described four sources of occupational stress: the stress associated
with documentation requirements and
a lack of time to complete paperwork;
experiencing difficulty with clients; managing relationships with coworkers; and
organizational culture. Counselors experienced occupational stress in different
ways and used a variety of coping strategies to manage stress.
Documentation Requirements
and Paperwork
Considerable time and effort must
be expended to meet documentation requirements associated with case management. The allotted time for these
requirements presented challenges to
counselors. Documentation standards
compete with the face-to-face time available to meet with clients. Managing case
files and providing the documentation
served as a source of professional stress.
The study revealed the need to consider how stress from documentation
requirements affected the delivery of
quality services. Federal and state documentation regulations ensure safety and
standard of care for patients, a necessary
component for counselors and organizations. However, high caseloads should
be lessened, preserving quality patient
care. Furthermore, learning effective case
management skills supports employee
growth and stress management.
I recommend “case management
coaching” (CMC), a term I devised.
Changes in service delivery systems,
licensure rules, and practice settings
challenge the profession and practice of
rehabilitation counseling (Shaw, Leahy,
Chan, & Catalano, 2006). These specific
changes, in combination with anticipated societal and professional trends,
have affected rehabilitation counseling
(Knudsen, Ducharme, & Roman, 2008).
CMC would assist counselors by pairing
them up with coaches (i.e., coworkers)
and helping them gain expertise in developing written reports regarding client
progress, treatment plans, developing
rapport/referral networks with other rehabilitation professionals, reporting to
referral sources, and financial decisions.
Coaching, through one-to-one learning,
advising, and nurturing, enhances personal and professional growth. Improved
case management skills bring clarity of
expectations and support to employees,
and improved performance (Robbins &
Judge, 2007).
Last, I recommend counselor professional development on managing time
and resources. Participants made it clear
they did not have enough time to complete
assigned tasks. Large caseloads and demanding circumstances require effective
time management skills. Staff training
and development in time management
may help to promote and maintain efficient and professional practices. Skagert,
Dellve, Eklöf, Pousette, and Ahlborg (2008)
found that lack of training and development causes time management and staff
morale to suffer.
9ldYf]YbW]b[8]ZÃWi`hmk]h\
Clients
Experiencing difficulty with clients
caused stress due the increased time
and demands associated with clients
in crisis. Concerns regarding chronic relapse; mental health issues beyond those
associated with treatment and recovery
for alcohol and drug addiction; and noncompliant behavioral issues about participation in treatment and recovery became
a challenge for counselors.
The study revealed drug addiction as
a complex disorder, involving virtually
every aspect of an individual’s functioning,
STRESS AND BURNOUT
including co-occurring addictive and
mood disorders such as major depression, dysthymia, and bipolar and anxiety disorders (Brady, Myrick, & Sonne,
2003). This interface of mood disorders
and substance use disorders acts as an
important factor in improving treatment
in the substance abuse field and has received a great deal of attention (Brady
et al., 2003).
I recommend a focus on clinical supervision. Two focuses of this supervision should involve job performance
and emotional support, creating a safe
space to discuss emotionally challenging
issues (Knudsen et al., 2008). The process of clinical supervision encourages
counselors to engage in self-reflection.
Research offered empirical support for
the relationship between clinical supervision and decreased emotional exhaustion (Knudsen et al., 2008). It may be that
supervisory relationships work to enrich
counselors’ ongoing experiences on the
job, thus moderating sensitivities to perceived stressors (Knudsen et al., 2008).
Managing Relationships
with Coworkers
Counselors described how relationships with coworkers become strained
due to workload. Excessive workplace
demands proved detrimental to building relationships with colleagues due to
the limited time available to get to know
each other. Participants’ workloads affected relationships with others in the
work environment, thus weakening organizational commitment. Organizational
commitment refers to the extent to which
employees identify with an organization
and feel committed to its goals (SikorskaSimmons, 2005). A lack of organizational commitment has been identified as a
strong predictor of staff turnover (KirkBrown & Wallace, 2004). Moreover, a
strong positive relationship between job
satisfaction and organizational commitment has been reported in numerous
studies (Kirk-Brown & Wallace, 2004).
I recommend self-managing teams.
Likert (1961) argued that an organizational
chart should depict not a hierarchy of individual jobs, but a set of interconnected
teams. Each team would be highly effective in its right and linked to other teams
via individuals who served as “linking
pins” (Bolman & Deal, 2008, p. 154). The
central idea in the autonomous team approach involves giving groups responsibility with autonomy and resources (Bolman
& Deal, 2008). Teams meet regularly to
determine work assignments and scheduling. Supervision typically rests with
an appointed or emergent team leader
(Bolman & Deal, 2008).
I also recommend autonomy-supportive environments to support feelings of
being in control among LADCs. Counselors
described the importance of having authority and flexibility to perform daily
tasks at a quality level, whether accomplishing this as individuals or working
with others in teams.
Organizational Culture
The last cause for occupational stress
involves organizational culture, which includes adapting to change, a lack of diversity, and racism in the work environment.
Counselors described stress associated
with constant changes in case management. Change undermines existing structural arrangements, creating ambiguity,
confusion, and distrust (Bolman & Deal,
2008). Counselors no longer knew what
was expected of them. Clarity, predictability, and rationality gave way to confusion, loss of control, and a sense that
“politics trumps policy” (Bolman & Deal,
2008, p. 383). To minimize difficulties,
organizations must anticipate structural
issues and work to redesign the existing
architecture of roles and relationships
(Bolman & Deal, 2008). Implementing
such environmental characteristics produces subjective well-being (Warr, 2005).
Next, participants maintained that a
lack of diversity affected them. Clients
and counselors of color interacted within
a predominately white managerial environment. Counselors of color described
this as racism and identified it as a cause
of stress. Participants desired an increase
in diversity in managers. Organizations
must recruit, support, and retain counselors and supervisors of color, reflective
of the client base.
To enhance culturally responsive services, staff members from marginalized
or socially oppressed groups need to feel
valued by individuals and organizations.
The value may be demonstrated through
processes allowing all members of the organization to compete on an even playing field, addressing factors within the
organizational culture privileging some
groups over others. Organizations overlooking the social and historical effects
of race privilege and racism risk perpetuating inequity through practices emphasizing the achievements and strengths
of white staff members without recognizing the cultural context supporting
their success (Blitz & Kohl, 2012). To address organizational racism, formation
and development of antiracist affinity
groups are recommended.
FUW]U`5ZÃb]hm;fcidg
As a goal, white staff members of social
work organizations understand institutionalized racism (Blitz & Kohl, 2012).
Individuals of the same racial group meet
on a regular basis to discuss the dynamics
of institutional racism, oppression, and
privilege within their organizations. Two
or more groups (organized by common
race identification) form and meet separately to identify and advance their organization’s racial equity goals. Race-based
caucusing may be an effective method
for social service agencies to highlight
race as they address cultural responsiveness (Blitz & Kohl, 2012). Caucusing can
function to promote antiracist practices,
advance organizational change, and support personal and professional growth of
group members. It fosters accountability
and validates perceptions of institutional racism within organizations, further
supporting the organization’s members.
Despite these potential benefits, there
is little evidence regarding the regular
use of race-based caucusing by agencies
(Blitz & Kohl, 2012). This may involve
concerns about competing resources,
difficulty envisioning concrete benefits,
and lack of clarity on how to begin and
manage the process over time. Antiracist
work needs special attention because
institutional racism downplays the role
of white culture and privilege, advancing the supposed ideal of colorblind
fairness, and discouraging talk about
white racial identity. These practices
tend to reinforce hidden privilege and
maintain, rather than eliminate, inequity
(D’Andrea, 2005; Perry & Shotwell, 2009;
Spanierman, Poteat, Beer, & Armstrong,
2006). A race-based perspective moves
organizations toward multicultural inclusiveness by stressing how racism and
racial identity development shape the
www.counselormagazine.com
39
STRESS AND BURNOUT
structure and performance of organizations (Shapiro, 2011). Examining how
institutional racism manifests may be
particularly complex because each may
define and experience racism uniquely.
Some members of the organization may
focus on the history of slavery, genocide,
and colonization, while others may refer
only to individual acts of prejudice or
bigotry. Organizations moving toward
the race-based perspective may, therefore, need to develop internal systems to
support staff members’ education and
develop a common language and way
of understanding structural racism and
other forms of systemic inequities (Blitz
& Kohl, 2012).
Blitz and Kohl (2012) identified the following principles for effective implementation of racial affinity groups:
Q Develop and maintain a regular dialogue about race and racism with
key people within the organization
and with outside consultants to
stimulate continued personal and
professional growth and enhance
creative problem solving
Q Clarify systems of accountability between the white antiracism caucus,
people of color, the institution’s executive management group, consumers of community members,
and other constituents
Q Regularly disseminate relevant literature on institutional racism,
white racial identity and culture,
white privilege, and antiracist practices to all members of the
organization
Q Work in harmony with and contribute to other organizational initiatives designed to address
institutional and cultural bias (e.g.,
making the workplace LGBTQfriendly, increasing access for
people with disabilities, and supporting religious inclusiveness)
Q Look for ways to weave an analysis
of power and race into other discussions of marginalization and bias,
and develop partnerships that enhance the organization’s evolution
toward genuine fairness and equity.
Q Executive managers should operate
with transparency, and discussion
should remain open to all individuals and subgroups involved in the
antiracism endeavor
Q White people involved in the caucusing process must be available for
evaluative dialogue with people of
color and others
Q Establish real avenues for critical
feedback to reach the senior levels
of management
Q Develop a shared mission or values
statement between the white antiracist caucus and the people of color
caucus that clarifies the intent and
goals of all racial affinity caucuses
Q Clearly state the expectation that all
white people within the organization will take an active role in confronting institutional racism as a
40
Counselor | June 2017
function of their job, and offer the
caucus as a means of support
Q Create forums, separate from caucuses, where employees who are
uncertain that issues of race and
racism are appropriate for the
professional setting can discuss
their concerns
Q When choosing members for caucuses, consider selecting participants from all levels of the agency’s
hierarchy
By implementing racial affinity groups,
a healthy racial dialogue takes place
within the agency and all staff members
and organization leaders may become
more adept at working within a multicultural, antiracist paradigm.
Leadership
For successful implementation of preceding organizational recommendations,
an effective leadership structure must be
in place. The large and growing literature
dealing with leadership has not led to an
obvious increase in either the quantity or
quality of leaders (Lyons & Schneider,
2009). Furthermore, leadership and burnout have mainly been examined as separate elements, and not enough attention
has been paid to the relationship between
these phenomena (Kanste, Kyngäs, &
Nikkilä, 2007). Better administrative support has been related to less burnout and
more satisfaction among substance abuse
counselors (Garland, 2004).
Compassion encompasses a transformation model. Northouse (2007) described transformational leadership as
an exchange occurring between leaders
and their followers, raising the level of
motivation and morality in both leaders and followers. These leaders attend
to the needs and motives of followers
and try to help followers reach their
fullest potential (Northouse, 2007).
Leadership development programs
should focus on introducing and supporting a more compassionate leadership to help counselors and clients
focused on the reduction of stress and
a healthy and balanced lifestyle.
Summary and Conclusion
My findings emphasized how the need
for competence and an inability to control demanding roles and expectations
caused stress among LADCs. Workloads,
family-work conflict, and racism affected
counselors’ confidence. Positive values
and role models may help counselors
become more proficient and gain new
skills and competencies. I fear organizations may think of this ideology as utopian. However, organizations serve as
competence builders, not only raising
people’s beliefs in their capabilities, but
also modifying structures to ensure success and avoiding placing people in situations that lead to failure. New counselors,
seasoned counselors, and leaders must
appreciate the importance of healthy organizations in combating the degree and
effects of stress and burnout. c
About the Author
Derrick Crim, EdD, LADC, CPPR,
MAPM, is currently an assistant professor at the Metropolitan State
University in St. Paul, MN, and is a
spiritual care professional for
Hazelden Betty Ford Foundation. Dr.
Crim has twenty-seven years of behavioral health experience. He has
his BA in human services from Metropolitan State
University, a master’s in counseling and addiction studies from Hazelden Graduate School of Addiction
Studies, and a doctorate in leadership from the
University of St. Thomas in Minneapolis. In addition, he
has a master’s degree in pastoral ministry (MAPM) from
the St. Paul Seminary and School of Divinity.
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41
CHAMPIONING PHARMACEUTICALS
Championing Pharmaceuticals
for Opiate Addiction:
AN INTERVIEW WITH
Behshad Sheldon
S
Andrea G. Barthwell, MD, DFASAM, &
Megan Crants, BA
he is a second generation IranianAmerican and the daughter of a prominent Persian cardiologist. She is a global
senior pharmaceutical executive with a passion
for serving the underserved. She is an esteemed
member of Female Opioid-Addiction Research
and Clinical Experts (FORCE), an organization
of women dedicated to combatting opioid addiction and its stigma. She is compassionate.
She is innovative. She is Behshad Sheldon.
Sheldon was born in Pontiac, Michigan, though she lived
in Iran from ages three to fourteen. During her childhood in
the Middle East, her father nurtured her intelligence, encouraging her to follow in his footsteps and enter the health care
field. “Sometimes people find it odd that I was told to follow
in my father’s footsteps, given that I was a woman back in
the 1970s in a Persian family, but that’s how it was,” Sheldon
laughed. She explained,
My dad was my North Star and always has been. He always
said, “You and your sisters can do anything you want to do.”
There were no boys, and in an Eastern family, as you might
imagine, especially back then, boys were very much coveted,
but we were all treated as we could do anything a boy could
do. We were forgiven for following in his footsteps and going to
medical school, and were always supported in whatever we
wanted to do. He not only taught me how to be a good person,
but even a good businessperson. My husband coined this about
my dad: he is a caretaker of life. He said that one time watching
him garden because he gardens with the same intensity and
attention that he would give to a patient in his office.
Sheldon had exceptional women as role models in her life as
well. “I know way more strong Iranian women than really strong
Iranian men in terms of who is the alpha in the household,” she
said. “For example, my best friend’s mom is kind of like a second
42
Counselor | June 2017
CHAMPIONING PHARMACEUTICALS
mom to me. She was the first woman pilot
in Iran and the first woman parachuter in
Iran. The women I knew were always doing
things that they thought they wanted to
do, and no one was going to stop them,”
Sheldon explained.
Upon moving back to the United States,
Sheldon found herself experiencing a bit
of a culture shock. “I entered high school
at a time when no one knew where Iran
was at all,” she said:
No one in my high school even seemed
to know where the Middle East was,
but when I said “Asia” a light bulb went
on. Ironically I had a British accent and
since no one had any idea where Iran
was, it all seemed exotic. My maiden
name, Behshad Dowlatshahi, made
me stand out as not being a typical
Eurocentric American from Michigan,
but people just thought of it as an exotic
thing so it was kind of cool.
But that was not to last. After the
Iranian Revolution and the Iran Hostage
Crisis in the late 1970s and early 1980s,
however, Sheldon noticed a definite shift
in opinion amongst her peers:
Suddenly everyone knew where Iran
was. I have to say that, though I never
experienced any personal backlash, I
definitely heard locker doors slamming
and people shouting “Nuke Iran! Let’s
nuke them to kingdom come!” and
similar sentiments as we’re hearing now.
It was definitely kind of an odd feeling,
but I didn’t take it personally. The only
thing we ever heard in our house is what
it means to be a Muslim. It means to be
a good human being. It means treating
everyone the way you want to be treated.
It means having respect for your elders.
It means taking care of those who can’t
take care of themselves. That’s what it
actually means.
Sheldon’s multicultural and varied
geopolitical exposure has notably been
an asset to her as a businesswoman and
as a leader in the health care space. She
has over twenty-five years of experience
directing pharmaceutical advancements
and commercialization around the world.
She explained,
I’ve had a lot of alliances where it was
required that I work with people from
other countries, mostly European, but
it still always came through to them.
They’d say, “You’re not what we expect
of a typical American person. You
understand that there’s another point
of view and perspective, not just the
American one.” That’s been a
tremendous help to me as a matter of
diversity of culture and thought, and
how we could make better decisions by
having all the perspectives in the same
conversation. Now it sort of seems like
a really sad day because what I saw
back then, the ability to use diversity to
make ultimately better decisions for the
company, for our shareholders, for
patients, for caregivers, is so torn apart
by everybody looking only at how
different they are. The worst part of it
is the loss of opportunity that comes
from loss of embracing diversity and
just calling somebody “the other” and
demonizing him or her.
thought, and the only way to have
diversity of thought is by having diversity
of experiences. He built his company
out of people of different backgrounds,
however you want to define that . . . any
experience that makes you different and
gives you a different perspective makes
you important to be included.
Mr. Otsuka acted as a role model for
Sheldon, along with several others at
each company she served, such as BristolMyers Squibb:
The sentence “Do the right thing for
patients, the rest will take care of itself”.
. . I think the first time I heard it was
from Sam Barker from Bristol-Myers
Squibb and he was the president and
CO at that time. So when people like to
beat up on Pharma, I have to say that
in all my time I’ve never heard anything
other than “put patients first.” That’s
why it just seems so natural; it was
always about doing the right thing.
Another really key person at Otsuka was
Caro Iwamoto. That was one of those
relationships where we were mentors
to each other because he was also a
philosopher scientist, but he didn’t really
know anything about commercial–
ization, so he asked me to teach him.
He in turn taught me, in different
techniques in enabling and authorizing,
to be creative and innovative.
Her worldliness and background
was particularly influential in her work
at Otsuka Pharmaceuticals, a Japanese
pharmaceutical company focused on excellence in global health care. Sheldon
spent ten years at the company and cofounded the Otsuka Princeton office in
her current hometown of Princeton, New
Jersey in 2002. She served as senior vice
president and was responsible for global
marketing, commercial organization,
alliance management, and early development strategy. She also served on the
board of directors of Otsuka’s Research
and Development sector, overseeing eighteen preapproval programs for products
in a wide variety of areas, including CNS,
cardio-renal, dermatology, oncology, and
pain. The Otsuka experience proved to be
formative for Sheldon, especially in terms
of work ethic and cultural awareness:
Sheldon has taken the sentiment “put
patients first” to heart, especially during
her three most notable drug launches:
Glucophage for diabetes, Plavix for heart
disease, and Abilify for psychosis. These
drugs are by any measure blockbusters,
both in sales and in impact. They have been
widely used in clinical settings and have
bettered the lives of millions. Sheldon said,
Mr. A. Otsuka was a visionary and
continually emphasized that we would
always put patients first. That was
something we always carried forward.
Innovation and creativity were more
important than process improvement.
These were the cultural principles. He
believed diversity of thought was the
pathway to innovation and creativity,
and that diversity of experience was its
foundation. He thought the only way
you could harness innovation and
creativity was by having diversity of
The key to success in all three of those
products was finding out what the
patient experience had been and where
it needed to go, what else patients were
looking for and how could we help them
get there. This is one of those things that
strikes me as different between the way
that men and women approach things
like pharmaceutical marketing; my idea
was always more like a live-together
strategy than a kill-the-competition
strategy. I just thought about, do places
exist where things can be combined so
www.counselormagazine.com
43
CHAMPIONING PHARMACEUTICALS
that the patient has a better experience?
It turned out in all three of those that
combinations with something else was
actually always a good idea because
you could minimize doses and side
effects and maximize efficacy. So they
just kind of build on each other. Another
thing all three of them had in common
was patients actually taking an active
role in their own treatment, whether it
was early patient education or posters
at bodegas or direct-to-consumer
advertising for Plavix. For Abilify
specifically, there was an enabling
patients idea that would lead them to
ask questions to their doctors and
hopefully end up with better care. I think
that ended up being another key thing
that seemed to lead to clinical success.
Sheldon has turned a bachelor’s of
science degree in neuroscience from the
University of Rochester into a head position at the pharmaceutical company
Braeburn Pharmaceuticals, which is a rare
and impressive feat. The organization primarily deals with central nervous system
disorders and the use of molecules that
are made available to patients through
novel delivery systems, and Sheldon’s
strong, compassionate presence as president and CEO has been vital in turning these goals into realities. Not only
has she worked to fully understand the
disease states and patient populations
she works with, she also tackles every
obstacle in her way to best serve those
populations. When asked what makes
Braeburn Pharmaceuticals stand out
from the competition, Sheldon replied,
We want to serve the underserved. We
want to go where Big Pharma and
maybe most other Pharma aren’t going
to go, which is to provide hope for
patients who are stigmatized and
whose diseases are vilified and at best
kind of ignored and swept under the
rug. We want to make a real difference,
not just make a twice-a-day drug to a
once-a-day drug. We want to do
something that will make a big
difference now, and that’s why we’re
dealing with molecules that are already
successful, but also investing in the
future in different ways of getting at the
problem. So, different kinds of solutions,
but always for people who get the short
44
Counselor | June 2017
end of the stick from society, people
who are marginalized and ignored at
best and vilified at worst.
In a letter of recommendation, National
Institute on Drug Abuse (NIDA) Director
Nora Volkow called Sheldon a “trailblazer” and a credit to women in health care:
She is at the very top of the list of
outstanding senior executive women;
her vision has engendered a proven
record of achievements that have
changed the health care industry for
the better. I have followed her
trailblazing career for many years and
have always been impressed with her
commitment to bring innovative
treatment options to treat chronic
From left, Behshad Sheldon with NIDA Director
Nora Volkow and Dr. Andrea G. Barthwell
diseases that are all too often made
worse by the shadow of stigma such as
opioid addiction, pain, and
schizophrenia. She has been a beacon
of steady leadership and clear vision in
an industry that can often be described
as stormy and unforgiving, focused like
a laser on serving patients suffering
from health conditions for which, for
too long, there has been little innovation.
In short, Behshad combines truly
unparalleled administrative and
professional accomplishments with a
strong and inspiring leadership style
that rewards diversity of thought and
encourages excellence. There is no
doubt in my mind that she represents
an exemplary role model for young girls
to follow and a much-needed reminder,
for every person with a passion, that
the fundamental values of hard work
and social responsibility still matter.
As president and CEO of Braeburn
Pharmaceuticals, Sheldon has been revolutionary not only in her successful product
launches, asset acquisitions, and research
developments, but also in her staffing
abilities. She has recruited an extremely
diverse group of individuals throughout
her career and has taken the time to train,
mentor, and appropriately promote them
across their professional lives. Her mentorship of other women has been notable, and she engages with patients and
physicians to get the understanding she
needs to push the boundaries of current
treatment landscapes within a disease
area. The time and effort she invests is
extraordinary and speaks volumes about
her passion to put people before profits.
For those individuals protesting Pharma
as a source of pure evil and corruption in
this world, Sheldon recommends going
back to the evidence and data:
There is a genetically defined void to
any kind of addiction. Pharma
marketing of opioids didn’t help, but I
wouldn’t even 100 percent agree that
this crisis was caused by those people.
I understand that we love to point
fingers, especially in this day and age
and in this country, but if we’re going to
point a finger, we should point it at the
disease. We have a problem in society
not teaching children how to deal with
stress, not training their brains to be
resilient. That’s our biggest problem.
But, no matter how you got to the point
of having the disease of addiction, we
think you deserve a way to survive and
thrive, and we are trying to provide a
solution. Also, looking at pain as the
cause of the problem will never fix it.
We shouldn’t sacrifice one group of
patients for another. This idea that we
should now stop treating pain because
a substance may be prone to becoming
addictive, that’s not going to work either.
The future looks bright for Sheldon
and for Braeburn Pharmaceuticals. The
company is currently investigating some
promising nonopioid molecules for the
treatment of addiction and pain. In addition,
Braeburn is trying to manage easy access
to Probuphine for as many of the right patients as possible and bringing new injectables onboard. For example, the company
is working on getting a new implant for
schizophrenia approved. Sheldon stated,
CHAMPIONING PHARMACEUTICALS
We believe that long-acting medi–
cations, like injectables and im plantables that guarantee adherence,
are essential to improving outcomes
and treating brain disorders, because
obviously when you don’t take your
medicine there are numerous bad
outcomes and consequences for
patients, their family members, and
society that can be avoided. The ability
to guarantee compliance is essential.
Things are already improving, and
that’s happening through education of
both doctors and patients and obviously
the longer the time, the easier it will be
for patients to accept the formulations.
If you don’t get people to accept and
overcome that, it’s a thorn in the side
of long-term program development. To
some extent it’s more about doctors
accepting these formulations, because
in some cases it just doesn’t jive with
their specialty. So for psychiatry it’s
pretty significant. They usually don’t
even have a sharps box in their office.
It’s quite a paradigm shift to figure out
how you’re going to deliver this different
formulation that you’re not used to
administering because you don’t
normally touch patients. It’s also about
the prevention of abuse, misuse,
diversion, and even pediatric exposure.
When we have formulations that are
administered by the doctor so you can’t
have pill mills, prescriptions for sale or
kids accidentally getting a hold of it,
that’s an added benefit to society and
certainly to the patients themselves
because they’re getting the dose that
the doctor wanted them to get.
American Society of Addiction
Medicine (ASAM) CEO Penny Mills found
Sheldon’s accomplishments to be quite
noteworthy, referencing in particular her
dedication to Braeburn Pharmaceutical’s
production of Probuphine:
Behshad worked tirelessly to overcome
hurdles with the FDA to bring an
extended-release formulation of
buprenorphine, a medication to treat
opioid addiction, to market in 2016. It
was Behshad’s compassion for the
patients and drive to expand the
narrow array of treatment options that
pushed her to overcome internal
challenges and work with the FDA on
next steps for Probuphine. With the
magnitude of the opioid epidemic,
Behshad’s leadership of Braeburn
Pharmaceuticals is an invaluable
contribution to the health care field.
“It’s quite a paradigm
VKLIWWRèJXUHRXWKRZ
you’re going to deliver
this different
formulation that you’re
not used to
administering because
you don’t normally
touch patients. It’s also
about the prevention of
abuse, misuse,
diversion, and even
pediatric exposure.”
Along with her work as CEO of a
flourishing pharmaceutical company,
Behshad is a leading figure in Female
Opioid-Addiction Research and Clinical
Experts (FORCE), an organization dedicated to preventing addiction to opioids,
making treatment widely accessible and
acceptable, and reducing opioid-related
damages. Sheldon explained,
The first idea of FORCE was statistical:
women make 80 percent of health care
decisions in the US. Having a group of
women who can speak to women about
what they can do to save their family
members, their loved ones, from opioid
use disorder and from the potential of
overdose and death seems like a logical
thing to do. However, the fact that we
balance, as women, the softer side, the
more caring side of things, the balance
of rationality and compassion,
definitely was a factor too. I’ve never
met quite so many women concentrated
in a specific therapeutic area, and I’ve
been in the pharmaceutical field for a
long time. There are so many brilliant,
dedicated women in opioid addiction
who are either doing research or
treating patients or both, it seemed like
it was waiting to be done to bring them
together so they can be part of making
a change and being part of treating the
opioid epidemic.
Fellow FORCE member and executive
director of public policy at Aimed Alliance
Stacey Worthy argued that Sheldon is
at the top of the list of most influential
health care leaders of 2016. “I have seen
firsthand her steadfast commitment to
helping millions of Americans affected
by the disease of opioid use disorder,”
Worthy said, “I am honored to have the
opportunity to work with Behshad to
promote individualized patient care.”
Behshad Sheldon has dedicated her
life to civic responsibility and has accomplished a great deal in the health
care field while still staying true to her
commitments of heart and conscience.
She is an exceptional individual who
has gained the respect of many and will
continue to better the lives of patients
all over the world. She has proven herself to be an outstanding senior executive; pharmaceuticals can be a cold and
unforgiving industry, but Sheldon has
stood steadfast in the face of adversity,
unafraid to be a woman with a passion
of heart. Her commitment to the disenfranchised masses speaks to her insight
as a modern leader and her determination to seek solutions to problems she
genuinely cares about. She has fully immersed herself in the patient experience
to better understand the unmet needs
of patients, and then set out to restore
their health with the drugs and formulations she has created. Keep an eye out for
Sheldon’s name in the future, as she is
surely destined for further greatness. c
About the Authors
Andrea G. Barthwell, MD, DFASAM,
is an internationally renowned physician who has been a pioneer in
the field of addiction medicine
within the American Addiction
Society of Medicine (ASAM) and a
contributor to the field of alcoholism and addiction
treatment. Dr. Barthwell currently serves as the medical director for Encounter Medical Group, PC, and is
the founder and CEO of the Two Dreams facilities.
Megan Crants, BA, graduated
from Johns Hopkins University in
2014 with degrees in cognitive science and writing seminars. She is
currently a clinical associate and
head writer/editor at Two Dreams
in Chicago.
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45
Transitioning from
9Zidm^ÄXVi^dcto
Addiction Treatment:
Facilitators and Barriers
Christine Timko, PhD, & Michael A. Cucciare, PhD
JSAT
D
HWR[LèFDWLRQWKHPHGLFDOPDQDJHPHQW Barriers
Barriers to the detoxification-to-treatment transition have
of substance withdrawal to prevent been
identified at the patient, program, and system levels. At
complications, does not serve as stand- the patient level, detoxification patients may resist treatment
because they are not motivated to stop using substances, or feel
alone care for substance dependence. Rather, that problems will get better on their own (Mowbray, Perron,
GHWR[LèFDWLRQVKRXOGEHDQHQWU\SRLQWWRDG- Bohnert, Krentzman, & Vaughn, 2010). Competing responsibilities of having a job and family, or lack of a stable living situdiction treatment. Successful transitions from ation or transportation, are barriers to treatment entry (Appel
et al., 2004; Kenny et al., 2011). Perceived stigma associated
GHWR[LèFDWLRQ WR DGGLFWLRQ WUHDWPHQW EHQHèW with
substance use and treatment need is a major deterrent to
outcomes such as reduced relapse, criminal seeking treatment (Mojtabai, Chen, Kaufmann, & Crum, 2014).
resist seeking treatment for fear of being labeled
justice system involvement, crisis-related Individuals
an addict, being negatively judged or treated (Allen, Copello,
health care utilization, and increased employ- & Orford, 2005; Luoma et al., 2007) or having repercussions
such as losing child custody (Boeri, Tyndall, & Woodall, 2011).
ment and stable housing (Ford & Zarate, 2010). Program characteristics also serve as barriers to treatment
utilization postdetoxification. These include wait times for
Nevertheless, many patients do not success- available
beds or appointments, requirements for meeting
IXOO\WUDQVLWLRQIURPGHWR[LèFDWLRQWRWUHDWPHQW eligibility criteria, and inconvenience of services (Appel et al.,
2004; Boeri et al., 2011). Wait times are exacerbated by staffing
(Carrier et al., 2011).
shortages and by staff members having heavy caseloads and
Facilitators
too many administrative tasks (Pullen & Oser, 2014).
System barriers such as cost and location limit addiction
services’ accessibility (Motjabai et al., 2014; SAMHSA, 2014).
Barriers to addiction treatment entry include lack of coordination across components of the health care system in qualifying,
enrolling, and supporting persons needing detoxification and
treatment (Appel et al., 2004). A lack of interprogram cooperation, communication, and collaboration deters addiction treatment availability following detoxification (Pullen & Oser, 2014).
Facilitators of detoxification-to-treatment transitions have
been identified at the levels of the patient, program, and
system. Patient-related facilitators of entering treatment after
detoxification include difficult circumstances caused by substance use, such as lost housing or relationships (Raven et al.,
2010), and pressures from friends and family to enter treatment (Kenny, Harney, Lee, & Pennay, 2011). They also include
personal motivation, often due to fatigue with the drug-using
way of life (Corsi, Kwiatkowski, & Booth, 2007). Increased drug Current Study
use, a recent overdose, health or legal problems, and previThis study used a conceptual model of determinants of
ous treatment admissions also facilitate addiction treatment health care transitions, which describes transitions’ patient-,
initiation (Jackson & Shannon, 2012; Siegal, Falck, Wang, & provider-, and system-level facilitators and barriers (Cucciare,
Carlson, 2002).
Coleman, & Timko, 2015). It used qualitative methods to inform
Program-level characteristics that are facilitators of ad- detoxification and addiction treatment providers, and the
diction treatment have been identified in both detoxification health care systems in which they work, about how to imand addiction treatment programs. Active discharge plan- prove detoxification-to-treatment transitions, by reporting
ning with clients during detoxification facilitated addiction detoxification providers’ views of transition facilitators and
treatment admission (Carroll, Triplett, & Mondimore, 2009). barriers. The aim was to identify factors that can be altered or
Transition rates may improve when addiction programs have transformed to improve addiction treatment utilization after
more clinically skilled, engaged, and supportive providers detoxification, and thus increase the likelihood of improved
(Broome, Flynn, Knight, & Simpson, 2007), and provide mo- patient outcomes and sustained recovery.
tivational enhancement therapy (MET) and peer support
(Blondell et al., 2011). The availability of case management, Participants and Procedures
women-only programs, and assistance with child care and
We interviewed thirty providers from thirty Veterans Health
housing may also improve addiction treatment rates (Rapp Administration (VHA) detoxification programs. To obtain this
et al., 2008; Sun, 2006).
sample, we used a VHA database to calculate, for each of the 141
One system-level characteristic that facilitates addiction VHA facilities during a single fiscal year (2014), the proportion
treatment after detoxification is detoxification treatment inte- of patients diagnosed with alcohol and/or opiate dependence
gration. Transfer rates from a detoxification unit to a rehabilita- who utilized detoxification and then obtained addiction treattion unit were highest when both units were contained within ment within sixty days. To ensure representation of a range of
a single setting (Ross & Turner, 1994). Integration across the facilities with regard to transition success, the fifteen facilities
continuum of care to address all of patients’ needs within a with the highest and the fifteen with the lowest proportions
single system enhances the likelihood of transitions between of patients obtaining addiction treatment following detoxification were targeted for participation. Project staff contacted
types of services (Appel, Ellison, Jansky, & Oldak, 2004).
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47
JSAT
each facility’s detoxification director or
main provider.
We used semistructured interviews
to examine participants’ perspectives
on facilitators and barriers—at the
patient, program, and system levels—
that affect patients’ transition from
detoxification to addiction treatment
(Cucciare et al., 2015). Interviews were
audio recorded and transcribed verbatim. Transcriptions were coded and
analyzed using methods derived from
grounded theory (Glaser & Strauss,
1967) with the qualitative data analysis
software program ATLAS.ti.
Results
The thirty detoxification providers
were mostly male (n = 16, 53.3 percent),
Caucasian (n = 22, 73.3 percent), and
had a mean age of 50.8 years (SD = 9.9).
Providers primarily had medical (n = 11,
36.7 percent) or advanced nursing (n = 10,
33.3 percent) degrees, and had a mean
of 10.5 years (SD = 8.8) of experience
providing detoxification services. They
described their detoxification patients
as typically middle-aged (forty to sixty
years old; N=17, 58.1 percent of interviews), of lower socioeconomic status
or homeless (N=23, 77.4 percent), having
utilized detoxification more than once
(N=25, 83.9 percent), and most commonly
detoxing from alcohol (N=26, 87.1 percent), although half of providers noted
a recent increase in younger, opiate-dependent patients (N=15, 50.0 percent).
Table 1. Patient Facilitators
and Barriers to Transitioning
Zfca8Yhcl]ÃWUh]cbhc
Treatment.
Patient Facilitators
N
1. Life context
a. Negative consequences
of substance use ............... 9
b. External pressure
or support to enter
treatment .......................... 8
2. Characteristics
a. Motivation for treatment ..
b. Previous treatment ...........
c. Proximity ..........................
d. Older age ..........................
4
3
2
1
Patient Barriers
1. Circumstances
a. Distance ........................... 17
b. Responsibilities ................ 8
c. Comorbid conditions ........ 8
d. Financial consequences ... 4
e. Justice-involved ................ 3
f. Environment...................... 3
2. Lack of follow-through
a. Stigma .............................. 11
b. Lack of motivation
for recovery ...................... 10
Note: N=number of providers who indicated the
facilitator or barrier theme
Patient Facilitators and Barriers
Providers’ interview responses yielded
The patient characteristic facilitattwo patient-level facilitators of the transi- ing the transition was being motivated
tion from detoxification to addiction treat- for treatment. P11 explained, “If you’re
ment: patients’ life context and patient going straight from detox into a treatcharacteristics (see Table 1). Regarding ment program, you’re pretty motivated
life context, patients were more likely to to be engaging in some kind of services
transition when they had suffered nega- because certainly no one can force you to
tive consequences associated with their go into treatment.” Characteristics also
substance use. Provider number two (P2) included previous experience with treatsaid, “The more they’ve lost, the better ment in that it lessens uncertainty about
chance I think there is that they will ac- what to expect, living in close proximity
tually engage treatment,” and P4 said, to treatment, and older age.
Patient-level barriers to detoxification
“Yeah, often a crisis will precipitate it,
like suddenly losing housing. Then they treatment transitions were represented
decide to get in treatment.” Patients were in two themes: patients’ circumstances
more likely to transition when their life and lack of follow-through (see Table
context involved pressure or support 1). Circumstances included being too
from others to transition from detoxifi- distant from or without transportation
cation to treatment.
to treatment; having responsibilities
48
Counselor | June 2017
that “compete” with treatment such as
employment or child care; having comorbid conditions like traumatic brain
injury or posttraumatic stress disorder
(PTSD); financial consequences of sustained treatment; involvement with the
criminal justice system; or living in a difficult environment, such as poor-quality
housing or lacking family support.
Financial consequences as a treatment barrier were explained by P23: “If
they have Social Security disability or
nonservice connected disability, after
ninety days we start taking funds from
them. . . . so the problem with a longer
stay is whatever their money source, they
might have trouble getting it restarted.”
The patient barrier of lack of followthrough was ascribed to stigma. P4 said,
“Some people, I think, don’t want the
stigma of being called an ‘addict.’ They
may not want to go to specialty care for
that reason. They prefer to see their primary care doctor.” Low motivation was
also identified with regard to lack of follow-through. As P6 said, “A lot of them
are much more entrenched in their addiction and sicker and the energy just
isn’t there.”
Program Facilitators and Barriers
Table 2 lists program-level facilitators and barriers of the detoxificationto-addiction treatment transition. One
program-level facilitator (see Table 2)
concerned the detoxification program’s
practices, including the provision of discharge planning and referrals to treatment.
P8 said, “When they come back for their
[detoxification] follow-up visit, that’s the
day I talk to them about ‘would you be
interested in maybe signing up for the
substance abuse treatment program?’”
Detoxification program facilitators also
included patient education and rapport
building with patients, as P5 explained:
“I think that’s just building a good rapport and being a good physician, good
clinician along the way. Because establishing trust is the best way you can go
on an individual level to get people in
when they come in.”
A second program-level facilitator
was the addiction treatment program’s
provision of evidence-based practices,
as listed on Table 2. A third programlevel facilitator, patient-centered care,
included providing a menu of options
JSAT
Table 2. Program Facilitators and Barriers to
HfUbg]h]cb]b[Zfca8Yhcl]ÃWUh]cbhcHfYUhaYbh"
Patient Facilitators
N
1. Detoxification program practices
a. Discharge planning and referrals..........................................................15
b. Patient education ................................................................................. 12
c. Rapport building ................................................................................... 5
2. Addiction treatment program provides evidence-based practices
a. Pharmacotherapy ................................................................................. 18
b. Cognitive behavioral therapy ............................................................... 17
c. Twelve Step facilitation and/or Twelve Step groups ............................ 16
d. Motivational interviewing, motivational enhancement therapy ............15
e. Relapse prevention ................................................................................13
f. PTSD treatment (cognitive processing, prolonged exposure) .............. 12
g. Contingency management .................................................................... 6
h. Harm reduction ..................................................................................... 4
i. Dialectical behavioral therapy ................................................................ 2
3. Addiction treatment program provides patient-centered care
a. Menu of options for help .......................................................................16
b. Special services for women ...................................................................16
c. Individualized treatment (patient needs and experiences) ................. 10
4. Addiction treatment program offers care coordination
a. Case management ............................................................................... 20
b. Housing ................................................................................................ 14
c. Engagement ......................................................................................... 10
d. Outreach ................................................................................................ 6
e. Peers ...................................................................................................... 5
5. Addiction treatment provides aftercare ............................................. 24
6. Addiction treatment is convenient
a. Immediate access ................................................................................. 11
b. After hours............................................................................................. 8
c. Provides transportation ......................................................................... 4
d. Telehealth .............................................................................................. 4
7. Addiction treatment staff is well-trained and professional ................ 17
Program Barriers
1. Lack of accessible addiction treatment
a. Wait time.............................................................................................. 29
b. No housing ........................................................................................... 12
c. Staff shortages ....................................................................................... 6
c. Not enough treatment beds ................................................................... 4
d. Limited hours ........................................................................................ 4
2. Addiction treatment programs’ inflexibility
a. Staff resistance ......................................................................................13
b. Strict policies .......................................................................................... 7
Note: N=number of providers who indicated the facilitator or barrier theme
for patients to consider as part of treatment—“There’s a whole set of groups
that look at relapse prevention, coping
skills, psychoeducation of the medical
complications, introducing people to
AA, relaxation training,” P9 explained.
Patient-centered care also included special services for women.
Within the theme of patient-centered
care, providers noted that facilitative
addiction treatment is individualized,
in terms of patient preferences for type
of addiction treatment (e.g., residential
or outpatient; individual or group), and
what patients experience in the type obtained. P2 stated,
We just make sure that the treatment
we envision for them is the treatment
that they need. We don’t really like
the idea of just shoving people into
groups without having a visit with
them, because there’s all kinds of
potential problems and their needs
may be different. They may have PTSD
so bad that a group may be impossible
in the beginning.
Providers also reported that the detoxification-to-treatment transition is
facilitated by the addiction treatment
program providing care coordination.
This consisted of regular case management within the program, and the
provision of housing while patients
are in addiction treatment. Programs
also made efforts to keep patients engaged with the health care system,
especially when wait-listed for or unwilling to consider treatment. At one
facility, addiction treatment services
assigned a nurse to call patients who
completed detoxification with reminders about treatment appointments. P11
explained, “For those who aren’t willing to go into specialty treatment, we
still have great follow-through with
them . . . keep working with them and
enhancing their motivation and working on their problems.”
Care coordination also included outreach to patients receiving detoxification
and their health care providers, to inform
them of addiction treatment services: “We
have interactions with their PC [primary
care] staff. If they identify somebody, we
will do some outreach with them, calling them, encouraging them to come in
and meet with us,” P12 stated.
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49
JSAT
Finally, care coordination also involved
peer support for transitioning, with peers
being either paid peer support specialist
employees or nonemployee Twelve Step
group members: “The increased support
of peer support specialists, peer involvement—and we’ve always had that from
the AA community. They really support
people getting into detox,” P3 stated.
Some providers regarded the addiction
treatment program’s provision of aftercare as a facilitator of the detoxification
treatment transition. That is, patients
continue to receive care after detoxification and addiction treatment completion.
Aftercare includes provision of outpatient
after residential care, and ongoing individual or group sessions after outpatient
care. P11 explained,
We provide follow-up for veterans as
long as they’re willing to engage in
follow-up. We have continuing care,
both individual and group, available
for as long as a veteran is willing to
engage with us. So we have veterans
who have been in recovery for fifteen
years and they keeping coming back
to group.
I think if there’s a pervasive attitude,
across everybody that they interact
with, that is professional, nonjudgmental, matter-of-fact but
concerned, but with a certain degree
of treatment optimism. . . . The more
that general philosophy pervades the
system, that facilitates people’s access
into treatment.
“Staff tend to have
particular biases—I
think sometimes some
of us don’t realize
where those lie and
how they can be
VLJQLèFDQWEDUULHUVWR
keeping people engaged
in treatment.”
With regard to program-level barriers
to patients transitioning from detoxification to addiction treatment, two themes
emerged (see Table 2): lack of accessible
addiction treatment and program inflexibility. Lack of accessibility covered wait
times between detoxification and treatment. P25 said,
Addiction treatment programs’ inflexibility that deterred transitions from
detoxification included staff resistance
to treating detoxification patients. P12
stated, “Staff tend to have particular
biases—I think sometimes some of us
don’t realize where those lie and how
they can be significant barriers to keeping people engaged in treatment,” and
P25 said, “The terminology seems to be
more punitive and judgmental towards
this population when they are cycling
in and out. . . . I think the judgmental
aspect actually gets in the way.”
Program inflexibility also included
strict program policies regarding patient
eligibility for services, as P25 stated, “We
find some of the programs to be kind of
frustrating in terms of their criteria. . . .
It feels as though there’s this narrow
window of eligibility that you’re either
too sick or not sick enough.”
An example of strict policies was at
P30’s location: when patients are administratively discharged for breaking
the addiction treatment program’s rules,
they are required to wait one year to reenter an addiction treatment program,
even if they complete detoxification at
any point during that year. P30 observed,
“And then you lose people quite naturally that return to using because they’re
denied services.”
Another theme with regard to addiction treatment programs’ facilitation of
transitions was programs being convenient; that is, patients have immediate
access to treatment after detoxification
System Facilitators and Barriers
completion. P11 stated, “If they’re inSystem-level facilitators of patients
The biggest problem in our whole
terested in going directly into specialty
transitioning
from detoxification to
continuum of care here is that
treatment, we can place them, for sure,
treatment
were
communication
between
typically a person who completes
if they’re willing to be flexible about
detoxification
and
addiction
treatment,
detox at our inpatient detox is going
their placement. And so nobody has to
to have to wait some weeks, even if integration of detoxification and treatleave detox without entering directly
they want to go to rehab and we ment, and hand-offs from detoxification
into treatment.”
agree with it, before they get to treatment (see Table 3). Communication
Also making addiction treatment
accepted and get an admission date. involved a good working relationship beconvenient was its availability after
. . . Then when they of course relapse tween the detoxification and addiction
hours (e.g., outside normal business
they have to be redetoxed to be sober treatment programs and providers: “I
hours, including weekday evenings,
to go into the rehab, which is not a just think it’s relationships, relationships,
weekends, and holidays), providing
relationships, and phone calls—that cogreat situation.
transportation to treatment, and offerordination of care that goes on between
ing treatment via telehealth.
Lack of accessibility also covered the facilities,” P3 stated.
Another theme that emerged as a fa- problem of patients having no housCommunication was related to the
cilitator of the transition from detoxifica- ing while obtaining treatment. P2 said, integrated, rather than sequential, protion to treatment was having well-trained “Some of these guys come from two, three vision of detoxification and addiction
and professional addiction staff. This in- hours away and I think the biggest prob- treatment services, as P18 explained,
cluded staff members having many years lem is trying to find them shelter in the “Detox is embedded within the specialty
of experience providing addiction treat- local area.” Lack of accessibility also clinic. . . . There really isn’t a transition
ment in a variety of settings (e.g., state included staff shortages and workload, at that point because it’s embedded.”
hospital, private agency), and being having too few treatment beds, and limFurthermore, integration of detoxiskilled and committed. P25 said,
ited treatment hours.
fication and treatment allows for warm
50
Counselor | June 2017
JSAT
Table 3. System Facilitators
and Barriers to Transitioning
Zfca8Yhcl]ÃWUh]cbhc
Treatment.
System Facilitators
N
1. Communication between
detoxification and
addiction treatment .............. 20
2. Integration of detoxification
and addiction treatment
(embedded and
simultaneous services) ......... 14
3. Hand-offs .............................. 13
System Barriers
1. Limited integration of
detoxification and
addiction treatment
(sequential services) ............... 6
Note: N=number of providers who indicated the
facilitator or barrier theme
hand-offs from detoxification to treatment. P19 said,
We work extremely closely—the
outpatient staff and the rest of the
staff—but the medication providers
work very closely geographically and
we have meetings and we’re always
available to talk to each other. So I
think it’s a matter of kind of warm
hand-offs. Kind of, “These are some
special things that I think are going on
with this patient that need attention.”
Only one theme appeared for systemlevel barriers to treatment after detoxification, which was limited integration
between the two services. P4 observed, “I
think integration could be better. You lose
people in between transitions. Inpatient
to residential works well. Inpatient to
outpatient, we tend to lose more people.”
Discussion
In this study, detoxification providers identified transition facilitators and
barriers at the patient, program, and
system levels. Most of the themes identifying facilitators of successful transitions focused on modifiable practices
of addiction treatment programs, but
modifiable factors were also identified
within the patient and system domains.
Patient motivation was seen by detoxification providers as related to the
detoxification-to-treatment transition;
its presence was a facilitator, and its
lack was a barrier (Corsi et al., 2007).
Considerable research has focused on
bolstering patient motivation in order
to facilitate initiation and engagement
with addiction treatment. Motivation is
viewed as a dynamic and fluctuating state
that can be enhanced (SAMHSA, 2013). In
light of providers in our study advising
that discharge planning and referral to
treatment should take place within detoxification programs to facilitate transitions, it may be possible to incorporate
motivational strategies during planning
and referral sessions (Vederhus, Timko,
Kristensen, Hjemdahl, & Clausen, 2014).
Motivational counseling approaches
may have the additional advantage of
helping patients consider other patientlevel transition facilitators and barriers
that detoxification providers identified,
such as negative consequences of substance use, and social support for obtaining treatment (see Table 1). In addition,
detoxification programs’ efforts to facilitate transitions via discharge planning
and referral, educating patients about
the benefits of addiction treatment, and
building rapport with patients (see Table
2) may need to be adapted for patients
with co-occurring problems such as the
presence of traumatic brain injury, PTSD
or criminal involvement, which were patient-level transition barriers. Patients with
these problems may face reduced frustration tolerance and problem-solving skills,
and increased disinhibition and impulsiveness, which can lead to poor choices
around health behaviors (Trudel, Nidiffer,
& Barth, 2007). Adaptations with regard
to detoxification programs’ transition facilitators may include addressing patients’
comprehension and memory challenges
by increasing the number of brief treatment planning and referral counseling
sessions while limiting session content
to help facilitate learning, retention, and
following through with new information.
Providers viewed patients’ negative
financial consequences of sustained
treatment and recovery as a barrier
to treatment transitions (see Table 1).
Disability income (e.g., Social Security),
provides a vital safety net to people
who need funds for housing and other
necessities, and substance-using individuals do not want to give up the stability provided by their disability benefits
(Rosen, McMahon, Lin, & Rosenheck,
2006). Resolution is needed at the policy
level to consider patient needs for both
disability payments and long-term, residential treatment stays to enable recovery.
Concerns that disability income is
associated with substance use (Rosen
et al., 2006) contribute to the stigma of
addiction being a barrier to treatment
after detoxification. Providers offered
that addiction treatment is less stigmatizing when it is available in primary rather
than specialty care. However, primary
care physicians report low levels of preparedness to identify and assist patients
with substance use disorders, in part because treating addiction is rarely taught
in medical school or residency training
(Shapiro, Coffa, & McCance-Katz, 2013).
Research supports the effectiveness of
integrated primary-addiction care, but
there are obstructions to implementation, including insurance and payment
issues, long-standing conflicting treatment cultures, and workforce issues
(Urada, Teruya, Gelberg, & Rawson, 2014).
Providers viewed addiction programs’
evidence-based treatments and aftercare to be facilitators of the transition
to treatment (see Table 2). Previous research found that programs offering evidence-based practices—those supported
by scientific evidence sufficient to merit
widespread implementation—were more
likely to have other positive attributes that
are similar to addiction-program-level
transition facilitators identified by our
sample (Power, Nishimi, & Kizer, 2005).
These attributes include the program
having the ability to provide patientcentered (reflecting patients’ preferences,
values, and needs) and individualized
(comprehensive, continuous over time,
and coordinated) care, and procedures
to ensure timely access to care. Such programs also had a strong process for developing and measuring staff competence
and providing appropriate clinical supervision, thereby ensuring the availability
of appropriately trained staff. Further,
such programs fostered a collaborative
model by ensuring staff communication,
which was a system-level facilitator of
transitions identified by providers in
this study (Power et al., 2005).
www.counselormagazine.com
51
JSAT
Whereas having well-trained staff was detoxification to treatment. Facilitators
a transition facilitator, staffing shortages of this care transition included delivering
were a barrier (see Table 2). There is a discharge planning and referral while regrowing staffing crisis in the addiction ceiving detoxification services, increasing
field due to shortages, high turnover the availability of evidence-based addicrates, an aging workforce, stigma, and tion treatments, and providing patientinadequate compensation. Research to centered, coordinated, and convenient
promote staffing retention suggests the care from well-trained and professional
usefulness of workplace interventions to staff. Findings are clinically useful because
enhance quality of worklife and reduce they suggest multiple options for quality
workplace stress and burnout, such as improvement efforts to increase treatment
providing staff members with greater entry and decrease the “revolving door”
autonomy, participation in work-related of repeated detoxifications. Identifying,
decisions, and career development op- implementing, and evaluating suggested
portunities; and enhancing leadership program-level approaches to facilitating
effectiveness and coworker relationships treatment transitions after detoxification
through teambuilding, conflict manage- are important for increasing treatment enment training, and clearer role expecta- gagement, improving patient outcomes,
tions (Eby, Burk, & Maher, 2010).
and reducing high-cost readmissions. c
Finally, care coordination within addiction treatment programs was a facil- Acknowledgements: This research was supported by
the Department of Veterans Affairs (VA) Substance Use
itator of the detoxification-to-treatment Disorder Quality Enhancement Research Initiative
transition (see Table 2), and case manage- (QUERI; RRP 12-525), and Dr. Timko by the VA Health
ment was important within this theme. Services Research and Development (HSR&D) Service
(RCS 00-001). The views expressed are the authors’ and
Case management is associated with do not necessarily reflect those of the VA. No conflicts of
treatment retention, patient satisfac- interest are reported by any of the authors listed on this
tion, quality of life, and reduced use of manuscript.
acute inpatient services (Rapp, Van Den
Noortgate, Broekaert, & Vanderplasschen, About the Authors
Christine Timko, PhD, is a senior
2014). Case management’s focus on col- research
career scientist at the
laborative problem solving regarding Department of Veterans Affairs,
barriers to treatment initiation, includ- Health Services Research and
(HSR&D) Service. She
ing helping patients identify feasible Development
is also a clinical professor (affiliate)
transportation options and overcome in the Department of Psychiatry and Behavioral
geographical barriers, may partially ac- Sciences at Stanford University School of Medicine. Her
research and mentoring focus on quality of care for incount for our finding (see Table 1).
dividuals with substance use and other mental health
Another solution to overcoming trans- disorders.
portation and distance barriers, under Michael A. Cucciare, PhD, is a core
the theme of making addiction treat- investigator at the VA Health
Services Research and Development
ment convenient for patients (see Table Center
for Mental Healthcare and
2), is the provision of telehealth services. Outcomes Research. He is the assoTelephone- and Internet-based screening ciate director of research training at
the South Central MIRECC at the Central Arkansas
and treatment, videoconferencing, and Veterans
Healthcare System. He is also an assistant prosmartphone mobile applications (apps) fessor in the Department of Psychiatry at the University
may enhance the flexibility of addiction of Arkansas for Medical Sciences.
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Detoxification providers identified
themes that suggest feasible approaches for improving the transition from
52
Counselor | June 2017
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Continued on page 58
Provider Self-Care
through Conscious,
Balanced Relationships
Elisabeth R. Crim, PhD
PROVIDER SELF-CARE
T
he very work of counseling and psychotherapy is relational. Those of us in
WKHèHOGXVHRXUYHU\VHOYHVDVDWRRORI
intervention. We actively utilize our knowledge and insight, training and clinical intuition, and our natural talents and the personal history that has shaped us to become who
we are. We attempt to effect change, health
and wellness, growth, increased insight and
awareness, and hope in those with whom
we engage and serve. We access these various aspects of ourselves as we interface with
our clients, patients, consumers, and the students and supervisees we train and guide.
the healing power of relationships. Whether we entered
the field with conscious intent or by accident, there have
always been unconscious processes and motivations at
play. Human beings unconsciously, continuously, recreate early relational attachment patterns and dynamics
with those we engage. Those of us who are health care
providers are no different. Much of our unconscious relational patterns incorporate relational defenses and longstanding attachment patterns, both with patients, clients,
students, fellow healers, and our friends, family, lovers,
and life partners.
We providers of care, healing, and service are, by the
very nature of our work, involved in relationships. By definition, our work requires that we be attuned to the needs of
others. In my work, I refer to the myriad of professionals,
paraprofessionals, and volunteers in these roles of providers as “healers.” The term is both metaphorical and true.
As healers, we are often required to attend to and navigate
the emotional and relational dynamics that each person
we serve brings with them. We are also required to navigate our own emotional and relational dynamics in this
process. Each of us navigates these relational dynamics
with varying degrees of self-awareness and consciousness.
These facets of our personality are also active, albeit someMany of us are quite good at navigating, as we have been
what differently, within our personal and intimate relation- doing it for most of our lives. Many of us attuned to the
ships with friends, family, lovers, partners, and children. care of others are naturally gifted in this act of attuning
As we move through our lives beyond our offices or treat- to others. We were born highly empathic and sensitive to
ment spaces to our homes, communities, and larger society, emotional states and relational dynamics. We often used
we are steadily utilizing these same attributes, skills, and these very skills to negotiate family dysfunction, power
knowledge to varying degrees. We do this even as we shop, struggles, and our personal and professional growth. Some
drive, plan our daily routine, prepare meals, stay present to call this “emotional intelligence” or “high empathic abilour partners and children at home and school, manage our ity” or “capacity.”
finances (personal and professional), and hopefully live a
And yet, within our culture of health, wellness, and
fulfilled, quality life.
education professionals, we are finally acknowledging
We can feel the pressure mount even as each addition- trends that can and do at times yield one of the hazards
al phrase of the last paragraph is read. Yet they are more of our profession. Our emotional intelligence, empaththan words. Those of us in the work of service—whether in ic abilities, and learned knowledge and skills fail us as
the profession of health, mental health, addiction, or our crises of compassion fatigue and burnout that are rooted
partnerships with education, police, fire, and other emer- in living lives of relational unconsciousness and imbalgency services—have professional lives that require us to ance do occur. It is a very real risk of our healing and helpfocus on others and their safety, health, education, and ing professions (Rothschild & Rand, 2006). Attunement
well-being. Many of us in these roles continue that focus on to others is often not balanced with attunement to self.
others in our personal lives as parents, partners, spouses, Conscious awareness of our own vulnerability and need
family members, friends, and as active social and commu- for care as a fellow human being is often lacking, forgotnity participants.
ten or purposely set aside. These patterns can result in
This is not to say that these various roles are simply put a crisis resulting from lack of awareness of our unconupon us; we are not victims. Those of us drawn to the fields scious ways of making meaning of relationships and the
of health, mental health, addiction, education, and ser- ever-shifting emotions that emerge in every interpersonal
vice in general, typically are drawn to relationships, to the interaction we engage, professionally or personally, sopeople in our lives through home, community, and profes- cially or intimately. “Self-care” has become the current
sion. We typically enjoy people. As a group, we are often cultural buzzword for attending to this phenomenon of
deeply fulfilled in helping and facilitating healing. We are compassion fatigue that can result in very real symptoms
generally pretty good with people. Engaging with people of imbalance and disorder that can express as physical,
and facilitating the growth and healing of others is part of emotional, mental, spiritual, behavioral (Portnoy, 2011),
what motivates us.
financial, and yes, relational dysfunction and disorder. I
As healers, many of us have felt a sense of being “called” will use the term “self-care,” as it resonates for so many of
to this work. We are often intrinsically fulfilledBarbara
through Krovitz-Neren,
us now. I also will
challenge you to join me in deepening
MA
our healing efforts and our attunement to others. We know its meaning to incorporate self-attunement and relational
54
Counselor | June 2017
PROVIDER SELF-CARE
consciousness and balance, and even
consider the psychodynamic concepts
of transference, an unconscious way
of organizing relational experience
based in early attachment patterns
and experiences.
The term “self-care” has emerged
as a global and highly generalized umbrella for multitudes of interventions for
and prevention of compassion fatigue,
burnout, and vicarious and secondary
trauma. From practicing yoga, tai chi,
qigong, meditation, and mindfulness,
to incorporating nutrition, breathing,
exercising, and taking vacations, each
is an example of a powerful approach
to self-care. Self-care has become a
steady drumbeat in the lives of those of
us who attend to the care, education,
intervention, and healing of others.
Over the last decade, awareness of the
very real and not uncommon experiences of trauma, fatigue, and burnout
within our professional lives is increasing across all fields of service—nurses,
psychotherapists, physicians, alcohol
and drug treatment counselors, police,
fire, and emergency professionals and
paraprofessionals. In my journey the last
several years of teaching and attending
to compassion fatigue and self-care, I
have repeatedly discovered that in addition to health, mental health, and
addiction professionals that mothers,
fathers, teachers, clergy, attorneys, financial planners, and even estheticians,
massage therapists, yoga teachers, and
veterinarians are affected and in need
of understanding regarding its reality
and needed intervention.
2015), understanding the concept of
relational transference as the root of
compassion fatigue and burnout is essential (Crim, 2015). And, unless these
unconscious ways of making meaning
of emotional and relational attachments and past and current relational traumas are explored and healed,
many healers will continually neglect
themselves and the very self-care interventions they value or espouse to
others. Further, research supports that
problems can arise in nonanalytic therapies when the transference between
therapists and clients is not attended
to by therapists (Gelso & Carter, 1994).
I would extend the importance of attending to transference that emerges
in all relationships by those within
those relationships when capable. I
wrote about this in an article specifically about transference:
The Power of Relationships
Just as infant neural networks, biochemical cellular and organ system
health, and immune system functioning develop through parent-infant attachment, so are new neural networks,
cellular health and immune system
functioning, and overall mind-body
health affected through current and
ongoing attached and meaningful relationships (Stern, 2000). Regarding the
neurobiological power of relationships,
As I teach and consult on the subject
of compassion fatigue and self-care, I
always address the deeper underlying
relational processes that lie at the root
of the issue. These relational processes are largely unconscious and can be
understood as psychological and somatic transference that is active and
affecting every healer, helping professional, and the people they are serving or treating. Though compassion
fatigue can develop from unresolved
single or ongoing experiences of vicarious and/or secondary trauma as
well as the sustained engagement of
empathy in response to trauma (Figley,
We typically think of transference as
a mental and emotional process in
which a therapist analyzes and
identifies the various ways that she
and her client are organizing and
making meaning of an emotional and
inherently relational experience
(Stolorow, Brandchaft, & Atwood,
1987). The process of developing new
[ways of organizing or making
meaning of relational experiences]
within the context of the therapeutic
relationship can also be now
understood as a neuropsychological
process as we [respect] the plasticity
and ongoing development of our
brains and neural networks throughout
our lives (Crim, 2009, 2012).
Dan Siegel (2001, 2007) [and Alan
Schore (2001, 2012)] echo Stolorow
(1987) neurologically as [they] discuss
the development of the brain in the
context of relationship, addressing
mirror neurons and the flow of energy
and information within one brain and
between two brains in the intersubjective field they share. The latter is
the process of both parent-infant
attachment and relationship and the
potentially healing developmental and
therapeutic therapist-client relationship
(Crim, 2012).
It can also be witnessed in the healing and generative power of conscious
and committed couples who experience enhanced mind-body-spirit relational healing and sense of well-being
as well as longevity through their safe,
intimate, and genuine relationship
with one another (Tucker, Friedman,
Wingard, & Schwartz, 1996). This mindful awareness enhances growth for all
relationships in which it is actively attended. Parent-child, friend to friend,
colleague to colleague, psychotherapist
to patient, counselor to client, nurse or
doctor to patient, husband to wife, lover
to lover. The healing and generative
power of self-care through conscious,
balanced, safe, and where appropriate, mutually nurturing relationships
can be astounding.
Somatic Transference
Healthy, connected relationships
afford more than emotional and
mental fulfillment. Living life within
the context of relationships in which
we balance attunement to self with attunement to others will affect physical,
spiritual, and even financial health as
well. In a 2012 article, I wrote,
A p e r s o n’s s e n s e o f s el f a n d
experience of relationship are more
than thought and emotion; both also
require body awareness to be complete. Body awareness is key in
experiencing and identifying emotion
and develops in the context of
relationship with self and with other.
Body awareness is often overlooked
by both therapist and client, [and
though improving,] ironically the
very field of mental health itself.
“Somatic transference” is a term I have
used to “capture the process of emerging
and often unconscious bodily states that
are activated within and between therapist
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55
PROVIDER SELF-CARE
and client in the shared relational space”
(Crim, adapted from Stolorow et al., 1987).
When I use the term “bodily,” I mean the
“. . . physiological, energetic, biochemical and/or neurological organizing activity of the intersubjective states between
two people that is inherently relational”
(Crim, adapted from Stolorow et al., 1987).
I explain this in an article I wrote on somatic transference:
The key to identifying mind-body
processes as “somatic transference”
lies in understanding that the bodily
expressions that emerge are not always
conscious or attended to (Van der Kolk,
1994; Ogden, Minton, & Pain, 2006).
We live in a society that trains us to
pl a y d o w n o u r ph ys i ol o g i c a l
disruptions, to negate the pain signals
when they sound. As therapists and
counselors, helpers and healers, many
of whom played the role of the helper/
healer in our family system of origin,
the denial of self for the service of other
can be deeply ingrained (Crim, 2012).
As previously noted, we often continue this pattern of self-denial in our personal and intimate relationships as well.
Examples of somatic transference may
include (Crim, 2009, 2012):
Q Feeling energized or physically
good entering a session, but tired,
physically drained following
that session
Q Experiencing headaches following
sessions or several sessions
Q Feeling sleepy or struggling not
to yawn with certain patients
Q Feeling lighter and energized,
physically better after meeting with
a certain client on a regular basis
Q Feeling the nervous system’s
heightened state and pulsing
adrenaline following a session
with a raging client
Q Reports of migraines or missing
sessions due to illness on a routine basis
Q Sitting stiffly on the edge of
the seat
Q Having physical pains while
discussing certain issues
56
Counselor | June 2017
Learning to pay attention to these
often subtle mind-body shifts within
ourselves, even while relating and attuning to others, is critical to maintaining our balance and health. Regardless
of setting and relationships, healers
and helpers can struggle in developing
healthy, committed personal intimate
relationships that are meaningful, balanced, and mutually nurturing; even
as they are successful in helping others
form them. And yet, relational health
is interconnected with physical, emotional, mental, spiritual, and financial
health. We arrive to these healer roles
as imperfect, imbalanced, and injured
souls in need of our own relational
nurture and attunement. We have our
own issues, transference dynamics,
and mind-body-spirit symptoms that
express these imbalances and injuries. Yet, it is easy in a field in which
the appropriate and ethical focus is
on the care of clients, patients or students to leave care, healing, and restoration of self to last. We increasingly
are learning how much of our mental,
emotional, physical (neurobiological
and energetic), spiritual, financial, and
relational health is mediated through
sustained, committed, healthy, attuned, and nurturing relationships.
When working with healers, I repeatedly find both for myself and others
that the shift in focus from others’
needs for healing and care to a focus
on healers’ own personal needs for
healing and care is often quite difficult. When I teach or lead consultation
groups—and even as I discussed the
issue with a trusted and highly selfaware colleague—the idea of exploring personal unconscious dynamics as
they emerge within us as healers can
easily slip into a focus on how those
dynamics affect those for whom we
provide care. While this is important
and ethically necessary, it often precludes an equally important focus: the
exploration of personal unconscious
relational dynamics for the sake of attending to our own holistic health and
wellness for its own sake. It seems that
for healers, the sustained focus on self
for our own personal health, wellness,
and fulfilling relationships with others
is often the most elusive. The difficulty
in sustained empathic self-inquiry and
self-exploration (Kohut, 1971; Stolorow
et al., 1987) often seems anchored at
least in part in a deeply ingrained and
unconscious organization of our past
and recurring relational dynamics,
attachment, and transference that is
based in early childhood, family, and
community relationships.
Early Childhood Factors
Sadly, some of us offered “inordinate caretaking” of our parent or parents for our own survival (Katehakis,
2014). It is not uncommon for healers
to have experienced parents or other
adults who required, most often unknowingly, that we empathically attune
to them, often to the neglect of our
own self-attunement and instead of
their attuning to us. For some healers there were grave consequences
for not taking on the empathic emotional and at times physical caretaking role of our parents. For others of
us it saved us from neglect and abuse,
even as less empathic and insightful
siblings suffered. For many in more
stable families, we found ourselves
gifted empathically in ways that differed from other family members, resulting in their depending on our gifts
in keeping the family’s emotional balance. Many of us were parentified as
children based on our ability to attune
to the need of the adults in our lives.
Since childhood, many healers have
formed friendships based in listening and giving to a close friend without allowing or requiring that same
care in return.
Many of us learned how to navigate
relationships, became highly attuned
healers, and developed our careers from
these early lessons, even if often unconscious, imbalanced, and at times full of
trauma. These unconscious states of
relational imbalance and transference
can also serve as unconscious psychological defenses that can actually keep
our partners, friends, children, fellow
colleagues, and coworkers in dependent and injured roles and identities.
Sometimes we choose to hide behind
our ability to focus on others effectively
without experiencing and revealing our
own vulnerabilities and painful emotional states. The psychological defenses
based in these relational dynamics can
PROVIDER SELF-CARE
also emerge between healers and the very
individuals we are endeavoring to help
professionally. Ultimately, as relates to
our own self-care, these unconscious
relational patterns and transference
processes will yield imbalances that lay
the groundwork for symptoms of compassion fatigue, vicarious and secondary trauma, and burnout.
Unconscious and often difficult or
confusing mind-body-spirit relational
dynamics that are based in our early
child and infant attachment experiences are active in our efforts to form
meaningful, safe, and trusting relationships personally and professionally.
Many therapists tend toward isolation
if not careful. Even though research
supports the powerful effects of collaborative, interprofessional treatment
teaming (Hammer et al., 2012; Crim,
2013; Crim & Fitzpatrick, 2003), many
are loathe or simply hesitant to do it for
more reasons than time and financial
constraints, which are real to be sure.
Many of us are unfulfilled personally
with family, friends, spouses or partners. Many are helping others steadily,
while quietly suffering privately. Sadly,
many of us experiencing this do not realize how not alone in this experience
we are. Further, many do not honor the
depth of which it is based in a repetitive
relational dynamic we have cocreated
with others since our early childhood
communities and families of origin.
Engaging in Self-Care
Due to these imbalances and unconscious dynamics, I have for years
taught that it is unethical for psychotherapists to not engage in their own
psychotherapy and ongoing consultation throughout their lives and careers.
I have taught that it is necessary to
understand the concept and powerful
effect of transference for providers and
the patients they treat or clients they
serve. In recent years I have evolved
to incorporate the reality that we are
mind-body-spirit beings. Somatic transference and physical symptoms expressing relational imbalance are real. Both
treatment for our clients and patients
and our own self-care routine must
therefore incorporate a somatic, mindbody healing practice of some sort. For
example, I collaborate to bring yoga,
acupuncture, and massage into my psychotherapy practice and consultation
groups. Additionally, the role of community is essential. Part of the powerful role of Twelve Step meetings is the
community, affording another form and
setting for meaningful and healthy affecting relationships. Some churches,
temples or community member organizations have also provided this in the
past. Though these settings are less utilized today as in past generations, the
need for safe communities and a shared
sense of belonging is no less essential.
We as healers need these as well.
We must seek balance
and self-awareness
as we attempt to
develop and engage
relationally and with
healthy attachment
with our personal family
and friends and
our community of
fellow healers.
For healers, unconscious and unattended relational attachment patterns and
transference dynamics can result in poor
self-care. The unconscious pull to attend
to others to the neglect of self is deeply engrained and often based in early attachment dynamics coupled with our natural
temperament and gifts. The latter can disrupt our ability to engage in conscious,
present, authentic, and genuinely connected and fulfilling relationships, both
personally and professionally. We need
safe, trusted, and mutual relationships.
We need communities in which we can
relax, take off our healer hat, and be our
true, genuine selves. In reality, many of us
are healing to others when we are in our
natural, balanced state. If we live from a
balanced, conscious, and mutually nurturing stance, we can also experience nurture
and healing from trusted others in our relational lives. For many healers, this may
be a new or unfamiliar experience. That
does not make it less essential; rather, it
suggests it is highly indicated in the selfcare regimen for mind-body-spirit health.
The process of our ever-shifting neurobiology, psychological and spiritual
processes, and the need for rebalancing both affects and expresses through
meaningful interpersonal relationships.
The conscious healer develops and manages relationships within her personal
and professional life. Intimate committed relationships, including marriage
or partnerships, children, parents,
family, close friendships, and trusted
colleague relationships require attention for sustained healthy attachment,
which affects the healer’s mind, body,
spirit, and finances, as well as her professional healing efforts. Healthy relational development requires attention
to relational transference, trauma, and
attachment dynamics and needs.
It is through the process of becoming conscious, self-reflective, and aware
within the context of our relational life
that we as healers can begin to experience fulfilling and genuinely connected relationships that enhance growth
and health at a mind-body-spirit level.
It is through conscious healing and restorative interventions that are insightoriented, transference-based, and
body-based that the latter attributes
can evolve and emerge with balance
and health. This process can all allow
us as healers to live a more conscious,
free, and vibrant life.
Self-care through the lens of relationship requires that we value the healing
and restorative power of relationships
in our personal and professional lives.
From a baseline of understanding that
we each live with injuries, blind spots,
and unconscious relational attachment
and transference patterns, we can begin
to actively seek personal psychotherapy
and professional consultation (peer and
paid) to attend to our unconscious attachment patterns, transference processes,
and unresolved trauma states. We can
remember to honor our natural motivations and talents and set a goal to live free
and vibrant lives. We must seek balance
and self-awareness as we attempt to develop and engage relationally and with
healthy attachment with our personal
family and friends and our community
www.counselormagazine.com
57
PROVIDER SELF-CARE
of fellow healers. Through this, we can
begin to value relationships within our
interprofessional communities, developing safe communities made up of trustworthy fellow healers from our shared
and other disciplines. We can begin to
approach treatment through a lens and
paradigm of collaboration and teamwork. It takes many healers from many
disciplines to truly attend to the holistic
complexity of a single individual, couple
or family. This is also true for ourselves
as the individuals who are the healers
needing the care of self. It is true of the
many clients, consumers, and patients
we serve. It is not only acceptable, it is
preferred that we not go it alone, personally or professionally.
To be a psychotherapist, counselor,
healer, and helper is a rich and wondrous calling. We can continue to enjoy
our journey as healers and live vibrant
lives throughout our many roles and relationships if we can heal relationally,
become more conscious, balance our
attunement to others with attunement
to ourselves, and learn to live life in a
manner that is relationally genuine, fulfilled, vibrant, and free. c
About the Author
Elisabeth R. Crim, PhD, is a licensed
psychologist and a certified relax
and renew yoga trainer, has a PhD
in psychology, and has MAs in psychology, theology, and counseling.
Dr. Crim is a speaker, author, psychotherapist, and consultant. She is
also the founder and CEO of
Moonstone Center.
References
Crim, E. R., & Fitzpatrick, J. C. (2003). Clinical update:
Childhood onset mental illness. Family Therapy
Magazine, 2(5), 34–40.
Crim, E. R. (2009). Dancing the transference: Honoring
the relationship between therapist and client. Clinical
Update: California Society for Clinical Social Work,
38(8), 1, 9–12.
Crim, E. R. (2012). Somatic transference: The body’s
process in psychotherapy. LA Therapist Update: Los
Angeles CAMFT Newsletter. Retrieved from http://
lacamft.org/wp-content/uploads/2012/01/LA-CAMFTJan-Feb-2012-Newsletter.pdf
Crim, E. R. (2013). Yoga therapy for mental health:
Understanding competence in the context of collaborative treatment teaming. YogaTherapyToday, 9(2), 16–8.
Crim, E. R. (2015). Compassion fatigue and countertransference: A mindful continuum of identification,
prevention, intervention. California Psychological
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Figley, C. R. (Ed.). (2015). Compassion fatigue: Coping
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Journal, 22(1–2), 7–66.
Hammer, D., Anderson, M. B., Brunson, W. D., Grus, C.,
Heun, L., Holtman, M., . . . Frost, J. G. (2012). Defining
and measuring construct of interprofessional professionalism. Journal of Allied Health, 41(2), e49–53.
Schore, A. (2012). The science of the art of psychotherapy. New York, NY: WW Norton & Company.
Katehakis, A. (2016). Sex addiction as affect dysregulation [Video file]. Retrieved from https://www.youtube.
com/watch?v=ni-rbehd5jo
Kohut, H. (1971). The analysis of the self: A systematic approach to the psychoanalytic treatment of narcissistic personality disorders. Chicago, IL: University of Chicago Press.
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K. Minton, & C. Pain (Eds.), Trauma and the body: A
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New York, NY: WW Norton & Company.
Siegel, D. J. (2001). Toward an interpersonal neurobiology of the developing mind: Attachment relationships,
“mindsight,” and neural integration. Infant Mental
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Siegel, D. J. (2007). The mindful brain: Reflection and
attunement in the cultivation of well-being. New York,
NY: WW Norton & Company.
Stern, D. N. (2000). The interpersonal world of the
infant: A view from psychoanalysis and developmental
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Stolorow, R. D., Brandchaft, B., & Atwood, G. E. (1987).
Psychoanalytic treatment: An intersubjective approach.
New York, NY: The Analytic Press.
Portnoy, D. (2011). Burnout and compassion fatigue:
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pages/healthprogress.pdf
Tucker, J. S., Friedman, H. S., Wingard, D. L., &
Schwartz, J. E. (1996). Marital history at midlife as a predictor of longevity: Alternative explanations to the protective effect of marriage. Health Psychology, 15(2),
94–101.
Rothschild, B., & Rand, M. (2006). Help for the helper:
The psychophysiology of compassion fatigue and vicarious trauma. New York, NY: WW Norton & Company.
Van der Kolk, B. A. (1994). The body keeps score:
Memory and the evolving psychobiology of posttraumatic stress. Harvard Review of Psychiatry, 1(5), 253–65.
JSAT
Continued from page 52
Rapp, R. C., Otto, A. L., Lane, D. T., Redko, C.,
McGatha, S., & Carlson, R. G. (2008). Improving
linkage with substance abuse treatment using brief
case management and motivational interviewing.
Drug and Alcohol Dependence, 94(1–3), 172–82.
Rapp, R. C., Van Den Noortgate, W., Broekaert E., &
Vanderplasschen, W. (2014). The efficacy of case
management with persons who have substance
abuse problems: A three-level meta-analysis of outcomes. Journal of Consulting and Clinical Psychology,
82(4), 605–18.
Raven, M. C., Carrier, E. R., Lee, J., Billings, J. C.,
Marr, M., & Gourevitch, M. N. (2010). Substance use
treatment barriers for patients with frequent hospital admissions. Journal of Substance Abuse
Treatment, 38(1), 22–30.
Substance Abuse and Mental Health Services
Administration (SAMHSA). (2014). The NSDUH report:
Substance use and mental health estimates from the
2013 national survey on drug use and health. Retrieved
from https://store.samhsa.gov/shin/content/NSDUH140904/NSDUH14-0904.pdf
Sun, A. P. (2006). Program factors related to women’s
substance abuse treatment retention and other outcomes: A review and critique. Journal of Substance
Abuse Treatment, 30(1), 1–20.
Trudel, T. M., Nidiffer, F. D., & Barth, J. T. (2007).
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Treatment models and challenges for civilian, military,
and veteran populations. Journal of Rehabilitation
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Rosen, M. I., McMahon, T. J., Lin, H., & Rosenheck,
R. A. (2006). Effect of Social Security payments on
substance abuse in a homeless, mentally ill cohort.
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Dependence, 68(2), 159–66.
Editor’s Note: This article was adapted from an article
by the same authors previously published in the
Journal of Substance Abuse Treatment (JSAT). This article has been adapted as part of Counselor’s memorandum of agreement with JSAT. The following citation
provides the original source of the article:
Substance Abuse and Mental Health Services
Administration (SAMHSA). (2013). Enhancing motivation for change in substance abuse treatment:
Treatment improvement protocol (TIP) series 35.
Retrieved from http://store.samhsa.gov/shin/content//SMA13-4212/SMA13-4212.pdf
Timko, C., Schultz, N. R., Britt, J., & Cucciare, M. A.
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CE QUIZ
Congruence as Self-Care:
Practicing What We Preach
Addiction Counselors in the
Compassion Fatigue Cycle
1. What percentage of counselors saw patients even
though they felt “too distressed to be effective”?
A Fifty percent
B Thirty-seven percent
C Sixty percent
D None of the above
%"HfiYcf:U`gY"¸7cadUgg]cbZUh][iY¹kUgÃfghXYÃbYXUg
the cost of sustained compassion and ongoing exposure
to suffering that can lead to secondary traumatization.
A True
B False
2. True or False. Most counselors have never been prepared
for the critical life mission of taking care of themselves,
since their jobs are so focused on caring for others.
A True
B False
3. The concept of “congruence” was introduced by what
therapist?
A James Prochaska
B Carl Rogers
C Eugene Gendlin
D Both A and B
4. True or False. Studies have found that a cohort-design,
mindfulness-based, stress-reduction program reduced
counselor stress, negative affect, rumination, and both
state and trait anxiety.
A True
B False
5. All of the following factors contribute to counselors
minimizing their personal issues, except:
A Social stigma
B Anticipated risks
C Fear of self-disclosure
D None of the above, these are all valid factors
2. Which of the following was not listed as a risk factor
for compassion fatigue?
A Budget constraints
B8]ZÃWi`hW`]Ybhg
C Unsupportive colleagues
D None of the above, these are all valid risk factors
3. All of the following were listed as early warning signs
for compassion fatigue, except:
A Hyperarousal
B Not distinguishing transference and
countertransference
C=bUV]`]hmhcYach]cbU``m`YUjYkcf_Uhh\YcZÃWY
D None of the above, these are all valid warning signs
4. True or False. One study found that receiving emotional
support and social connectedness from counselors and
supervisors in the workplace was an important factor in
sustaining counselor well-being.
A True
B False
5. Which of the following were not listed by Fahy as
alternative treatments for addiction counseling?
A TREM and NT
B MI and NT
C NT and CBT
D Both A and B
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Make checks payable to Health Communications, Inc. D`YUgYU``ck'hc*kYY_gZcfbch]ÃWUh]cbcZmciffYgi`hgUbXmcifWYfh]ÃWUhYcZWcad`Yh]cb]ZmcidUgg"MciaUmkUbhhc_YYdUWcdmcZh\]gei]nUgUfYWcfXZcfmcif`]WYbg]b[VcUfX"I"G>cifbU`HfU]b]b[ =bW" ]gUbUddfcjYXdfcj]XYfZcfWcbh]bi]b[YXiWUh]cb\caYghiXmVm.B558575ddfcjYX9XiWUh]cbDfcj]XYfDfc[fUa$$$%-(/7:55D#775DDDfcj]XYfCG!,*!$)+!$)%,/75589Dfcj]XYf75-'$'%!+%)&/7568cZ6Y\Uj]cfU`GW]YbWYgD7:+,ZcfA:HgUbX@7GKg/
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VcUfXhcXYhYfa]bYWcifgYUddfcjU`ZcfWcbh]bi]b[YXiWUh]cbWfYX]hg"GcW]U`kcf_dfUWh]WYWUhY[cf]YgUfY]bhYfaYX]UhYhcUXjUbWYX`YjY`g":cfeiYgh]cbg [f]YjUbWYg cffYZibXgd`YUgYWcbhUWh@cff]Y?Y]d!7cg]hcfYUh,$$,)%!-%$$Ylh"&&$"
62
Counselor | June 2017
CE QUIZ
A Phenomenological Study of Stress
and Burnout Experienced by Licensed
Alcohol and Drug Counselors
%"5WWcfX]b[hch\YUih\cf @587g]XYbh]ÃYX\ck
many different sources of occupational stress?
A Seven
B Ten
C Five
D None of the above
2. Which of the following is not one of the
listed occupational stress factors?
A Money
B Balancing work and family demands
C Both A and B
D None of the above
3. True or False. “Organizational commitment” refers
to the extent to which employees identify with an
organization and feel committed to its goals.
A True
B False
("5``cZh\YZc``ck]b[UfY`]ghYXUgUfYUgUÃbUbW]U`
literacy program would focus on, except:
A Budgeting
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C Record-keeping
D Economic stress
5. True or False. Clients and counselors of color interacted
within a predominately white managerial environment,
but nevertheless, they stated that a lack of diversity did
not directly affect them.
A True
B False
Counselor Magazine Evaluation Quiz
Scale: 1 (low) – 5 (high)
Presenter (USJT)
Knowledgeable in content area
1 2 3 4 5
Content consistent with objectives
1 2 3 4 5
Content
Infortmation was suitable and useful to course topic
1 2 3 4 5
Article was appropriate to my education
and licensure level
1 2 3 4 5
Information in the article was current
1 2 3 4 5
Appropriate for intended audience
(Intermediate to advanced levels)
1 2 3 4 5
Clarity of content
1 2 3 4 5
Support
Did you need to contact the Program Administrator?
1 2 3 4 5
Learning Objectives
Congruence as Self-Care: Practicing What We Preach
%"8YÃbY¸Wcb[fiYbWY¹UbXk\Uh]haYUbg]bfY`Uh]cbhcWcibgY`cfgY`Z!WUfY
2. List various ways studies have found of enhancing self-care
3. Identify factors that contribute to counselors leaving self-care unaddressed
4. Explain how a counselor’s appearance, behavior, and conduct affects
client interactions
Addiction Counselors in the Compassion Fatigue Cycle
1. Provide counselors with alternative treatment methods to avoid burnout
2. Recognize early risk factors for compassion fatigue
'"9ld`U]b\ckW`]Ybhg»¸hfih\hY``]b[¹WUbfYgi`h]bgYWcbXUfmhfUiaUZcfWcibgY`cfg
("5bU`mnY\ck¸Vifbcih¹]gX]ZZYfYbhZfca¸WcadUgg]cbZUh][iY¹
A Phenomenological Study of Stress and Burnout Experienced
by Licensed Alcohol and Drug Counselors
1. List personal stress factors that can contribute to burnout in counselors
2. Describe various occupational issues that can cause stress for counselors
3. Provide suggestions for reducing stress across various areas in personal life
and at work
("8YÃbYfUW]U`UZÃb]hm[fcidgUbX\ckh\YmZibWh]cb]bh\Ykcf_d`UWY
Earn 1.5 continuing education credits by completing the following
quiz. Pass with a grade of 75 percent or above and you will be
UkUfXYXUWYfh]ÃWUhYcZWcad`Yh]cbZcf%")bUh]cbU``mWYfh]ÃYX
continuing education hours. This is an open-book exam. After
reading the indicated feature articles, complete the quiz by
Ã``]b[ ]b cbY cZ h\Y Zcif ai`h]d`Y W\c]WY UbgkYf ViVV`Yg" 6Y
sure to answer all questions and to give only one response per
question. Incomplete questions will be marked as incorrect.
Send a photocopy of the page along with your payment of
hkYbhmXc``Ufg"6YgifYhcdf]bhW`YUf`mUbXZi``mWcad`YhYh\Y
information section.
CE quizzes are available online at
www.counselormagazine.com.
It’s quick and easy, no stamp needed!
www.counselormagazine.com
63
INSIDE BOOKS
The Trauma Heart:
Stories of Survival, Hope, and Healing
Judy Crane
Reviewed by Leah Honarbakhsh
sharing her knowledge and expertise,
The Trauma Heart features heartfelt and
moving poems and artwork to provide
even more meaning and depth to what
the book is trying to relay.
Judy Crane, author, therapist,
speaker, and founder of Florida’s The
Refuge and The Guest House treatment centers, is no stranger to trauma
and drug abuse. In the introduction
to her new book, The Trauma Heart:
Stories of Survival, Hope, and Healing,
Crane writes,
“. . . as long as I live,
life brings challenges.
I face them in the
\YfYUbXbck UbX]Z=Xcb¾h I pay the price of
XYYdYfdU]b"¼
I have been shot and stabbed and
had many black eyes and broken
bones. I have been arrested multiple
times and I have been held physically
and emotionally hostage. I have spent
three weeks in a psychiatric hospital
with methamphetamine psychosis,
and a shattered elbow in a cast . . .
In my wildest dreams, and I have
many wild and amazing dreams for
my life, I never would have expected
to find recover y at forty-two,
complete my master’s degree at age
fifty, become licensed as a therapist
at fifty-two, and start a treatment
center at fifty-seven . . . I have
always been a “late bloomer.” In
my wildest dreams, I never expected
to be a leading voice for trauma
treatment or trauma resolution or
the many aspects of the intertwining
of trauma and addiction, trauma
and mental health, and trauma and
behaviors. I am a therapist, a
teacher, a writer, and a thought
leader. I stand on stages all over
the world and openly share my
experience, my strength, and my
hope. I am an expert at helping to
heal wounded souls of trauma, and
I could never have imagined a
greater life’s purpose to make a
living amends for my past.
This is why readers will find that
Crane is uniquely poised to write and
share stories of healing and hope to
those who have experienced trauma
in their lives. Through The Trauma
64
Counselor | June 2017
Go to hcibooks.com
and enter code
WWRBOOKS
to save an additional
20% off!
At the end of each chapter, Crane
presents readers with insightful questions by means of reflective sketches
and assignments, urging them to take
a more active role in reading the book
and applying it to their own lives. Some
of the questions Crane asks are,
Q “Why did you buy
The Trauma Heart?”
Q “Do you have secrets
that you’re keeping?”
Heart, Crane helps readers relate to
their own histories; examine the meaning of trauma and addiction; and really
engage in the reflective sketches, the
assignments, and the personal stories
provided in the book.
The Trauma Heart shares personal
stories, stories of a variety of Crane’s clients, and stories of a variety of trauma
issues—from childhood sexual abuse
and PTSD to addiction issues and selfharm. She tackles the nature of secretkeeping, relapse, overdose, and many
other factors that contribute to trauma.
Aside from client stories and Crane
Q “Has your ‘shininess’
been tarnished?”
Q “Have you ever said to yourself,
‘I will not do or say what my
parents or caregivers did?’”
Crane writes that healing her “‘trauma
heart’ has been the greatest gift, and I
continue that work today with my own
therapist because as long as I live, life
brings challenges. I face them in the
here and now, and if I don’t, I pay the
price of deeper pain.” The Trauma Heart
aims to help readers do the same: learn,
heal, and ultimately “dream big” and
live their lives to the fullest. c
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