by Kambria Kennedy-Dominguez
We just wrapped up our very first art therapy series at Flourish, and it was a great success. We found the physical and emotional expression of painting images, shapes, and colors on canvas to be a soothing exercise. Painting, drawing, and creating are ways to do something with emotional experience. Counseling is often about defining what you feel. And often clients ponder this question out loud, "so I know what I feel, what do I do with it?" Most often I answer, "accept". You don't need to do anything with the feelings, except acknowledge and accept.
What you do is better based on what you value, not on what you feel.
Still, sometimes we need some kind of release, expression, resolution, and way to cope with the myriad of emotions that most of us feel every day. Anger, sadness, worry, regret, indifference, fear...to name only a few....are difficult to sit with. So if we can take a walk or a run, go a yoga class, snuggle with our partner or our pet, read a good book, take a warm bath, or paint a picture, these activities may help us endure and sit with the feelings.
Because of the success of the first art therapy 5 week series, we are offering it again, and hope to make it a staple of our services at Flourish. During the series, participants will learn how to use art as a relaxation exercise, how to incorporate meditation into the creative process, and how to build self-compassion. Part of our mission is to help others find what healing practices work for them, whatever that happens to be! Check out all of our groups here.
Let's give anxiety some consideration today. You've likely experienced it over and over. You may have heard about certain types of anxiety like phobias and panic attacks, or diagnoses like Generalized Anxiety Disorder or Panic Disorder. There are lots of levels and experiences of anxiety, and sometimes even different definitions of anxiety from person to person. Anxiety is essentially worrying, feeling afraid, overthinking, and sometime panicking.
The common thread is that anxiety exists and is real for all of us, because it stems from an innate human emotion...Fear.
The DSM 5 (the manual we look at to classify symptoms and diagnose) draws a distinction between fear and anxiety like this:
The autonomic nervous system, referenced above, pays a particularly important role in anxiety, and has two distinct parts. It revs us up (courtesy of the sympathetic system), then stabilizes us (thanks to the parasympathetic system), when there is a perceived threat in our environment. Imagine a bear chasing you...your heart rate increases, breathing rate increases, blood flows to limbs, pupils dilate, digestion slows, muscles tense. Sometimes tunnel vision and hearing loss occur, as well as relaxation of the bladder and colon. This very physical response to danger has a purpose. Muscles tense to ready themselves for action, blood flows to limbs to enable us to move quickly away from danger. Then, the nervous system slows and reverses this response once danger has passed, initiating relaxation. Our breathing and heart rate slow down, our muscles relax, our body comes back to homeostasis.
Both humans and animals alike experience this stress response cycle. Animals and humans differ, however, in the ability to reason, classify, predict, and analyze. We humans can thank our bigger brains and cerebral cortex for that. An animal might encounter that same bear, have a fight or flight response, be able to escape from danger, then quickly stabilize and move on. The cerebral nature of our human brains don't allow us to move on in the same way. We would likely have persistent fear or worry after an episode like that. We may feel afraid of bears, the place it happened, what we did right before it happened, that we may not protect ourselves from it happening again, or that it will happen to someone else. You can see how the human mind's ability to analyze gets us in a pickle here.
We can get stuck with our fear in the "on" position, even in response to more innocuous stimuli like work or school demands, relationships, financial issues, health concerns, parenting, and other aspects of daily life. Our reasoning and predicting minds create future scenarios to worry about, and sometimes with good reason. If you lost a job in the past because you were late, you may be well served to worry about being late in the future. So in this way, anxiety is a helpful and useful tool that reminds us to pay attention to something specific like not being late to work. However, as we know, anxiety can become problematic when it immobilizes us in everyday life, keeps us from making decisions, disengages us in things we'd like to do, or impedes relationships.
Here's how I describe the anxiety continuum. Remember, fear and anxiety are related to paying attention to our environments and paying attention is a good thing.
It may be helpful to outline the different types of anxiety disorders listed in the DSM 5.
In counseling, there are many approaches to working with anxiety. I've found three approaches most helpful:
For more information on how we incorporate these approaches into therapy, please contact us! We are happy to help you learn more about how counseling can work to manage fear and anxiety.
By Kambria Kennedy-Dominguez
What "sobering up" means to you depends on your situation. Sometimes it means decreasing the frequency or quantity of use. Called "harm reduction" in treatment terms, many people naturally do this when they notice a problem with drugs and alcohol but are unsure of its severity. For example, if you find that you binge drink (more than 4 drinks at a time for women and more than 5 for men) when you're out with friends at bars, you might decide to ask your friends to meet you at a movie instead of a bar. Shifting the environment in which problematic behaviors occur is a way to reduce harm. Likewise, you may try to limit the amount you are drinking or using, or you may make deals with yourself not to use at certain times of day or in certain places. All of these methods of control are common once a problematic pattern is recognized. Whether these methods of control work or not depends on your individual circumstances. Here's a guideline for the safe consumption of alcohol, by the way. Great graphic from the CDC.
Harm reduction is controversial, because many treatment professionals and many of those in recovery believe complete abstinence is the only way to sobriety. They might say that attempting to reduce harm only keeps you in the dangerous cycle of addiction, as you try to negotiate the problem away. There are reasonable arguments in favor of abstinence as the best strategy and it does indeed seem to work best for many. Taking a harm reduction versus abstinence approach is a very personal decision, one that I help clients make based on their own experiences.
Depending on the severity of the addiction and on the substances or substance combinations being used, withdrawal may with abstinence. Withdrawal symptoms range from mild to severe and vary depending on the drug. The process of withdrawal under medical supervision is called detoxification, and is the safest way to discontinue use of a drug when withdrawal is present, particularly with alcohol, opiates (heroin or prescription pain killers) and anti-anxiety drugs (like Xanax and Klonopin). After detox, many continue to residential treatment for 30 days or more, and some choose to move into sober living environments after residential care. These are each options along the way to sobriety, and most everyone's journey looks different depending on what they need.
Once a more sober life is established, you have entered "recovery." Below is the three part plan that I use with counseling clients to help sustain recovery.
Using coping skills that work
A critical part of therapy for anyone, whether addiction is present or not, is learning to identify and use coping skills that work. What do you do when you feel stressed out at the end of a busy day? What do you do when you fight with your spouse? What do you do when you come up short on your monthly bills? What do you do when your boss yells at you? These are just some examples of possible triggers (see above) that may lead to cravings to use if there are not more adaptive coping skills in place. Some examples of coping skills are exercise, art, reading, talking to trusted friends, 12 step groups like AA, support groups, meditation, spending time with pets, making music, listening to music, walking, drinking tea, taking a warm bath, having a massage, giving yourself a massage, learning a new skill, taking up a new hobby....the list is limitless really. The question to ask yourself is how can I soothe myself in a way that doesn't create harm?
Recovery is possible and it's happening for many people every single day. There are a ton of resources available to help and lots of evidence that positive change is within reach. If you are struggling with addiction or wanting to know more, please don't hesitate to reach out.
by Megan Kennedy
The mental health community is buzzing with talk about stigma. As a social work student, my mental health classrooms were filled with dialogue about the ongoing consequences of shaming individuals with mental health problems. As a professional, the effects of stigma are often detailed in the stories and everyday lives of my clients, and as an individual with a lengthy history of anxiety, I have personally felt the effects of stigma and witnessed stigma through others close to me. Considering roughly 18.6% of adults and 13.1% of children (ages 8-15) suffer from diagnosable mental health problems, chances are you have too. Most of us agree that stigma is harmful, but where does it come from and what can we do about it?
Researchers report two distinct types of mental health stigma - social stigma and self- stigma. Social stigma results from prejudice attitudes and discriminatory actions that target individuals with mental health issues due to the assignment of psychiatric labels. Self-stigma, on the other hand, is characterized by one’s internalization of perceptions of discrimination.
A number of factors contribute to stigma. Historically, individuals with mental health concerns have been treated differently, rejected and abused. Dr. Graham Davey, a British professor of Psychology, notes that this kind of treatment stems from mistaken views that mental health problems steer people to act in more violent or unpredictable ways than those without such problems, or somehow people with mental health concerns are abnormal or different. However, none of these views have any basis in fact. Dr. Davey also includes the medical model as an unintentional source of stigmatizing beliefs, as this model usually signifies diagnoses and diagnoses implies a label to a “patient.” Such labels are often associated with undesirable attributes, which perpetuate the idea that individuals with mental illness and/or diagnostic labels should be viewed with concern.
It’s no surprise that the most blatant perpetuation of mental illness stigma is at the hands of the media, as media portrayals often reinforce stigma with images of violence and homicide associated with mental health problems. Discussions concerning mass shootings and mental illness almost go hand in hand these days. Moreover, words used to represent mental illness are so common in our present-day vocabularies they almost always pass without comment or judgment. Psycho. Nut-job. Crazy. Insane. He’s lost his mind. She has some serious OCD. The list continues.
For some, the nastiest consequences of stigma aren’t social injustices but the effect stigma has on help seeking behavior of those affected by mental health problems. The Scattergood Foundation reports a mere 30% to 40% of people with mental health problems seek treatment in the U.S., and up to 70% of adults and youth worldwide do not receive services for mental and behavioral health problems. Public health researchers attribute stigma as a major causative factor driving these alarmingly low rates of treatment. Moreover, stigma hurts treatment outcomes and hinders effective recovery from mental health problems.
The good news is, there are many simple actions we can all take to help challenge mental illness stigma which include:
John Gottman, marital therapist and researcher, identified four patterns of communication that are most disruptive in intimate relationships, so disruptive in fact, that they are predictors of divorce in married couples. I've found that describing these patterns to couples in counseling has been helpful in resolving communication problems. Gottman wrote about them in his book called The Marriage Clinic, calling them the "Four Horseman of the Apocalypse." (I'm on the fence about that name, but it is kind of amusing and easy to remember.) Here's a summary:
So what to do when you see the four horseman appear in your relationship?
Most importantly, know that a healthy relationship is not devoid of these negative patterns of communication. All relationships struggle. The goal is not to avoid having problems in your relationship, but rather to focus on healthy repairs when ruptures occur.
Healthy repairs include recognizing when you are criticizing, defending, stonewalling, or contemptuous. Talking through differences with willingness to have the difficult feelings that come along with them is a healthy step toward mutual understanding. A couples counselor can help guide these difficult conversations in a productive way, and provide the couple with the tools to accept difficult emotions. Counseling also provides neutral territory where everyone's points are equally valid and everyone has equal opportunity to express their needs.
Sleep is so important that almost every single diagnosis in the Diagnostic and Statistical Manual for Mental Health Disorders (or DSM) has a disrupted sleep component to it. That's why I ask every client about sleep on the initial paperwork when entering counseling. I have conversations about sleep so frequently in counseling sessions, I decided I needed to gain more information and new ways to explain what happens while we are sleeping. There happened to be a great article about this topic in the November issue Counseling Today, a periodical published by the American Counseling Association.
It turns out there are two critical periods to your sleep cycle. The Stage 3 NREM phase is crucial for physical health. Your immune system and cells regenerate. It's called recovery sleep. The system in the brain which creates the stress response (the hypothalamic-pituitary-adrenal axis and the sympathetic nervous system) is powered down. We spend the most time in this kind of sleep and it seems to be akin to recharging our batteries.
The Stage 4 REM sleep phase enhances our emotional health, allowing us to keep our feelings in check so that we can function in our day. Emotional memories are encoded during this phase and are separated from the actual emotional response, allowing us to retrieve these memories from a distance and not get so overwhelmed in them again, as if they were happening all over. People with trauma histories have a particularly disrupted Stages 3 NREM and 4 REM cycles, resulting in the inability to process memories and deactivate the stress response.
See the below graphic for more details about all the stages of sleep.
For more on sleep hygiene and an excellent sleep diary, visit the National Sleep Foundation. You can improve your sleep by avoiding caffeine, alcohol, and heavy meals in 2-3 hours leading up to bedtime. It also helps to have a bedtime ritual at the same time every day, engaging in an activity like reading, relaxation exercises, gentle stretches or drinking herbal tea in the hour before bedtime. And exercise in the early afternoon seems to have a positive effect on sleep quality.
Here's to a restful night's sleep!
The healing power of setting foot in a counselor's office...it's a thing.
A client and I were recently wondering, is there a name for this? I don't recall learning about it in school, or reading research about it. I don't recall a textbook definition of one word that sums it up.
"Just by coming here today, I feel a relief."
Then, it happened again. Another client says to me after several weeks of appointments and lots of emotional work, that the most powerful part of counseling was the decision to come and keep coming back. Then a few weeks later, again, I hear the sentiment in an initial session with a new client. "Just by coming here today, I feel a relief." In these statements, I hear that to have sought out help, made the call or sent the email, set up the appointment, and stepped foot in the door...these actions alone make a difference.
I like metaphors. They are helpful in giving us new perspectives on old material. So for instance, we may have an idea of what counseling is about. We may have an idea that it's for people who are broken. Or that it's for people in crisis. Or that it's for people who are severely mentally ill. Or that it's an absolute last resort when nothing else works. These associations are powerful. That's our old material at work.
But what if we create new material here? What if we think about counseling as a sunrise, a dawning of a new day? Let's imagine the last time we couldn't sleep at night...how frustrating it is not getting the sleep we want, worrying about what will happen the next day if we don't sleep. Then we imagine ourselves putting our insomnia to work for us. Maybe we walk to the kitchen and make a cup of tea and sit with ourselves and reflect. Maybe we take a hot bath to calm our nerves. Maybe we massage our hands or temples to create ease. All of these steps are actions that make a difference in our insomnia. We greet a new morning, perhaps not with a great night's sleep, but with a sense that we cared for ourselves through the process.
Likewise, the steps toward seeking out counseling are actions of self-care. They are messages to ourselves that we are worth it, that a new day can dawn, and that we can connect to another human being even in the midst of pain. Pain has a purpose in this way. It can bring us closer to others, to what we seek, and to our true nature.
Carl Rogers believed, and research has shown, that the power of the therapeutic relationship is what creates change through counseling. The connection to another human being is the substance of change and hope. The permission one grants themselves in arranging the words of their story and sharing them with another person with the intent to make change...this is the mechanism by which counseling works. This is the way that new perspectives, new beginnings, and new sunrises are born.
So my responsibility as a counselor is to continually invite these moments to occur in the lives of others. And to meet each person and each story with unconditional positive regard, empathy, and honesty. The dawning of a new day is a brilliant display to witness.
Yoga is an ancient practice that originated far away. It has made its way around the globe in a wave of both physical healing and spiritual awakening, while simultaneously becoming a multi-billion dollar industry in the US. Some of the yoga teaching in the west has been simplified to a mostly physical practice by this commercialization and popularization, however yoga's philosophical foundation as a way to live a good life endures as well. These days, yoga is practiced not just in affluent studios, but also in schools, prisons, hospitals, and apparently on aircraft carriers (love this picture.)
Thanks to modern science and research, we also know much more about how yoga impacts physical and mental health than ever before. Let's explore some things we know about how yoga helps, and then describe how this knowledge can be incorporated into a traditional talk therapy session.
What Research Shows
From Ross, A., & Thomas, S. (2010). The health benefits of yoga and exercise: A review of comparison studies. Journal of Alternative & Complementary Medicine, 16(1), 3-12. doi:10.1089/acm.2009.0044
How Yoga and Counseling Are Combined
Here's a description of how I combine yoga and counseling. Other therapists/yoga teachers may do it differently, and chances are, my own style will keep evolving the more I learn from my clients what works best.
Individual counseling sessions can include yoga, if and only if, the client thinks it will be helpful. Yoga in session can range from simple seated stretches, to intentional work with the breath, to standing and seated poses on the floor. In the intake and beginning phases of counseling, personal goals are identified, and as we explore these goals through talk therapy, I will be thinking about how certain yoga postures or sequences may be helpful. We will talk about using yoga in this way, then plan a time to incorporate it, or go ahead and use it at that moment. The way that yoga is used in counseling is always up to the client, and my suggestions as counselor are just that... suggestions.
For instance, a client who is struggling with self-image may be asked to try a yoga sequence that feels familiar and accessible, and notice their self-talk during the movement. How compassionate are their thoughts toward self? Are thoughts about self-image coming up? Are they critical? Then the client may be cued to work through a more challenging sequence and notice how the self-talk changes. After a few minutes of yoga (usually 15-30 minutes during an hour counseling session), I will sit with the client either on our yoga mats in an adjacent studio or back in the counseling office to discuss their experience, share what internal self-talk arose, describe how their physical or emotional state changed in response to the movement, and so on.
Another example is a client who is experiencing social anxiety. The client may have a goal of learning new ways to manage anxiety so that it doesn't stop them from going out with friends. The client may notice a tightness in the chest or throat when thinking about going out with friends. So to address it, I might ask a client to imagine that they are about to go out with friends, notice in detail the sense of constriction or tightness they are experiencing in the chest and throat, then use some guided breathwork and throat opening stretches, while seated in the counseling room to work with the sensations.
We can also work with yoga in group sessions. My ideal way to combine yoga and counseling in a group is to use a mixture of both physical yoga postures and discussion and/or personal reflection. My experience of vinyasa flow sequences is that often emotional "stuff" will come up as we move the body. As we work into the creaky, rarely accessed parts of our joints and tissues, an emotion may arise. Then from that emotion, a chain of thoughts may arise: memories, anticipations, judgments, regrets, etc. Taking time after a yoga practice to reflect on these emotions and chain of thoughts can help to move through them, put them away, or take more time attending to them. This can be accomplished through internal self-reflection, group discussion, or both.
In this upcoming group yoga workshop, we will practice a one hour vinyasa flow class, then we'll take a short break and come back together to process our experiences. I will provide some paper and pencils to help participants process their yoga experience through writing or drawing. I will provide some prompting questions to help participants explore their wellness in several core areas shown below. I like this "Indivisible Self" model because it prompts us to think globally about what impacts wellness. (Myers, J. E., & Sweeney, T. J. (2005). The indivisible self: An evidence-based model of welIness (reprint). Journal of Individual Psychology, 61(3), 269-279. )
After we've processed internally, I'll offer a chance for participants to share and discuss their self-reflections. This part is absolutely optional, as some might prefer to keep their reflections private. A very important component of using yoga with group counseling is that all members agree to keep one another's shared thoughts and feelings confidential. Maintaining confidentiality is a key guideline and expectation for the participants in this type of group.
In summary, we know that a regular yoga practice is helpful for many different conditions, ranging from chronic illnesses, to mental illnesses, to adjustment-related problems, to general stress and anxiety. We also know that talk therapy is helpful for these conditions. Combining yoga and counseling involves, first and foremost, respect for the client's autonomy and ability to choose the direction of therapy, along with gentle reminders toward self-compassion, self-acceptance, and an attitude of self-exploration in both body and mind.
There are so many experiences of work that are negative, and many that are positive. Sometimes we are so caught up in the tasks at hand, we don't notice how we feel about them at all. Here's a chance to step back away from the work you do and see it more clearly.
First, consider what is work? (As a quick aside, did you know the counseling field developed from the work of career counselors in the early 20th century? Because of this, all of us who get an advanced degree in counseling must take an entire course on Career Counseling. In this course, we are asked to define work. It turns out to be a worthwhile question!) So work is... the hours of the day in which you are at your place of employment. Right? Or when you work at home? Like reading emails after hours? Or working in a home office? Or worrying about your day at the office tomorrow while you're trying to relax at home? Is that work? What about stay at home moms or caregivers for older family members? They aren't paid but they are working, aren't they? They do all their work at home, but it's still work right? What about doing chores on the weekends when you're "off" work. Don't chores still feel like work? What about volunteering? You're not getting paid, but it's still work, yes? Wow, ok, maybe it's not that easy to define work.
After much reflection in Career Counseling 101, I came up with this conclusion...Work is any way in which we use our energy to accomplish a goal that will benefit both ourselves and others. Work is getting out of bed, making a meal, taking care of your children or your pets, doing your chores, going to your job, doing the tasks of your job, paying your bills, working out (notice how we use the word "work" here but for most of us, it isn't a job!) What do you think? The point is that sometimes our thinking about work is misleading, like it's a certain set of places or activities that are discretely different than the rest of life, when actually, it is in many ways inseparable.
It may help to identify some of the elements of satisfaction or dissatisfaction at work.
Then mark them on a scale like pictured here. Make a bunch of these lines and put a tally mark there on the line for each of the different elements we identified. You may be highly satisfied with some aspects of work and dissatisfied with others. Some of these elements may be more important than others, so take that into consideration, then you can rate your overall satisfaction with your work based on the elements that are most important to you.
Now that you've isolated the aspects of your work that are good and not so good, take some time to ask yourself, how much of your evaluation of your work has to do with past work experiences? Think about your very first job in which you had absolutely no reference at all for how work is "supposed" to be? What was your evaluation of it? Likely, each of your work experiences has built upon one another to create a set of expectations in each of the above areas. It's useful to know which of your work experiences are the most powerful in how you evaluate your current situation. You may really miss a good boss you used to have, and now your current boss just can't live up to your expectation. You may have had a great salary at a previous job, and be carrying unresolved grief about losing it to your next job that doesn't pay as well. You may have had a past boss that was a real problem for you, so you might stay in an unfulfilling job with a great boss because you fear getting another horrible one. It's worth doing these tally marks with past jobs, to help you get some clarity on your perspective about your current job.
Finally, consider how you define success. Is it happiness? Wealth? Independence? Doing work that matters to you? Doing work that makes you "come alive"? Almost everyone's definition of success is tied up with their early childhood experiences at home and school. Those times when your parents or teachers were proud of you or disappointed with you. Those times when you grew into your own sense of success, independent of, or contrary to, what others thought. It's worth asking yourself this question, "Would the person who I respect most in my life think I am successful in this work?" If the answer if yes, you are likely to also consider yourself successful. If it's no, you may be longing for something fundamentally different in your work life.
The key to defining success may the awareness that it's not a destination but a journey. And that successful moments happen all day every day, even when we don't notice them. Take a step back and see if you notice them.
Also, let's not fool ourselves into believing that we need to "come alive" each and every day, all day long in our work in order to deem it "successful." The fact is that work is mundane by its very nature and there will be times, even in the best job, that we are bored and dissatisfied. That said, we are likely "coming alive" in our work at times without noticing it, and we can most likely simply do a better job of noticing.
Here are some good resources for work-related issues:
Being mindful is a term used frequently in our society today, and the scientific study of mindfulness is relatively new. From self help articles to blog posts to academic literature, there is a wealth of information available and research to show that creating a mindful attitude can help us deal with many of life's challenges. The seminal work in mindfulness is Jon Kabat-Zinn's 1990 book, Full Catastrophe Living. The "full catastrophe" is the suffering that all humans experience in some way or another, and mindfulness teaches that we can live a full and healthy life even in the midst of the catastrophe. Kabat-Zinn founded the Stress Reduction Clinic at the University of Massachusetts Medical School, where he is also the Executive Director of the Center for Mindfulness in Medicine, Healthcare, and Society. He has created an approach to difficult emotional and physical states called Mindfulness Based Stress Reduction, or MBSR. Since 1979, over 14,000 practitioners have been trained in this method.
So what is mindfulness? There isn't a widely agreed upon definition yet. However here are a few...
"Mindfulness is awareness. It's paying attention, on purpose, in the present moment, non-judgmentally." Jon Kabat-Zinn
"Mindfulness is the practice of knowing what's happening in the mind without getting hijacked by it." -Rick Hanson
So what is your sense of mindfulness from these descriptions? Does it seem like a concept that's hard to wrap your head around? Does it seem far removed from the reality of those days with 1000 things competing for your attention?
The way I've described mindfulness lately has to do with a train. I've used this metaphor while teaching yoga classes and in therapy. Take a listen to the train meditation here.
Mindfulness does have to do with meditation and going into the mind, but meditating is not the goal of mindfulness, nor is mindfulness created only through meditation. Meditation provides a place to practice and a window into a mindful state of awareness. This state of of awareness is not a special place you visit while meditating, but rather is just your natural state of being while paying attention to what's happening in the present moment, or "non-meditation."
Kabat-Zinn emphasizes that non-meditation is what we are really after in our everyday life. Because we can't stop, sit, and meditate during the most difficult and busy parts of the day, we need another way to cope with stress. Mindfulness, then, with intentional practice, can be applied as awareness of each present moment as it arises, wherever we are. Learning to be aware of your thoughts, feelings, and bodily sensations in the midst of chaos is really what mindfulness is about.
Kambria Kennedy-Dominguez, Counselor and yoga teacher specializing in mental health, substance abuse and wellness.