Intimacy
Trauma, Addiction, and Intimacy Prodependence Interviewing the Psychopath, Part II Psychoeducational Treatment for Family Members The Official Magazine of the California Consortium of Addiction Programs and Professionals (CCAPP) October 2018 Vol. 19 | No. 5, $6.95
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CONTENTS
4
Letter from the Editor
22
By Gary Seidler Consulting Executive Editor
Trauma, Addiction, and the Flight from Intimacy
6
CCAPP
Sober-Living Regulations throughout the Nation, Part I
By Janae B. Weinhold, PhD, LPC Describes a model of optimal human development, presents examples of the codependent and counterdependent stages, and explains effective therapies.
By Lillie W. Singh, Esq.
9
NACOA
28 Prodependence: A New Paradigm for Relational Counseling By Robert Weiss, LCSW, CSAT-S Introduces the term “prodependence,” provides a history of codependence, and lists ways to promote prodependence in clinical practice.
When Words Are Not Enough: Why Experiential Forms of Healing Are Desirable in Treating Relational Trauma By Tian Dayton, PhD, TEP
11
Opinion
Intimacy in Counseling
By D. John Dyben, DHSc, MCAP, CMHP
Wellness
Slow Down, You’re Going Too Fast, Part II
14
By John Newport, PhD
33
Topics in Behavioral Health Care
Interviewing the Psychopath, Part II
16
The Benefits of Gratitude
By Norman E. Hoffman, PhD, EdD, LMHC, LMFT, Wendy L. Rippon, PhD, LMHC, and Valerie Watt, PhD, LCSW
By Dennis C. Daley, PhD
Explains how anxiety can predict psychopathy, provides case examples, and evaluates treatments for this population.
Counselor Concerns
The Personal Journey of a Nonalcoholic through the AA Twelve Steps
From the Journal of Substance Abuse Treatment
38
19
By Gerald Shulman, MA, MAC, FACATA
Ask the LifeQuake Doctor
Evaluating a Program for Concerned Family Members of Individuals with SUDs
By Toni Galardi, PhD
By William J. Denomme, BA, and Orry Benhanoh, MSW, RSW, RFMT
Ad Index
Describes a study on the effects of substance use and concurrent disorders on concerned family members and provides treatment implications.
CE Quiz
21
Also in this issue:
2 46
CE Quiz instructions are on page 2 and 47
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1
CE QUIZ INSTRUCTIONS A Health Communications, Inc. Publication
Intimacy
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Trauma, Addiction, and the Flight from Intimacy Page 22 Describes a model of optimal human development, presents examples of the codependent and counterdependent stages, and explains effective therapies. a. Explain reasons why people flee from intimacy b. List various findings from the author’s research on trauma, individuation, and intimacy c. Describe event trauma and developmental trauma d. Expound on what the author means by “heart-centered and relational support”
Prodependence: A New Paradigm for Relational Counseling Page 28 Introduces the term “prodependence,” provides a history of codependence, and lists ways to promote prodependence in clinical practice. a. Define the new term “prodependence” b. Explain the origins of codependency c. Analyze the ways loved ones of addicts can practice prodependent ways of caring d. List research studies that found how isolated and separated individuals suffer more than individuals with emotionally intimate connections
Interviewing the Psychopath, Part II Page 33 Explains how anxiety can predict psychopathy, provides case examples, and evaluates treatments for this population. a. List various physical and mental symptoms of anxiety b. Clarify how anxiety may be related to psychopathy c. Summarize the case studies and the specific issues facing each patient d. Explain treatment recommendations for therapists and others working with psychopaths
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Counselor | October 2018
Counselor (ISSN 1047-7314) is published bimonthly (six times per year) and copyrighted by Health Communications, Inc., all rights reserved. Permission must be granted by the publisher for any use or reproduction of the magazine or any part thereof. Statements of fact or opinion are the responsibility of the authors alone and do not represent the opinions, policies, or position of Counselor or Health Communications, Inc. Subscription rates in the US are one year $25.95, two years $44.00. Canadian orders add $15 US dollars per year, other international orders add $31 US dollars per year payable with order. Florida residents, add 6% sales tax and applicable surtaxes. Periodical postage rate paid at Deerfield Beach, FL, and additional offices. Postmaster, send address changes to: Counselor, PO Box 15009, North Hollywood, CA 91615 - 5009 © Copyright 2018, Health Communications, Inc. Printed in the USA. President & Publisher
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Advisory Board
Robert J. Ackerman, PhD, Chairman Joan Borysenko, PhD Ralph Carson, PhD Tian Dayton, PhD Bobby Ferguson David Mee-Lee, MD Don Meichenbaum, PhD Pete Nielsen, CADC-II Cardwell C. Nuckols, PhD Mel Pohl, MD Mark Sanders, LCSW David E. Smith, MD
AD INDEX CCAPP.............................................................................................................7 Foundations Recovery............................................................................... .13 Jack Canfield One Day to Greatness............................................................3 Joan Borysenko........................................................................................... 11 Journal of Substance Abuse Treatment......................................................10 HCI Books.....................................................................................................44 Heart Reconnection.....................................................................................43 Newport Academy.........................................................................Back Cover Prodependence........................................................................................... 48 Toni Galardi..................................................................................................21 USJT Calendar..............................................................................Inside Front USJT Newport..............................................................................Inside Back USJT New York............................................................................................ 17 USJT Scottsdale.............................................................................................5
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LETTER FROM THE EDITOR
Is There an End in Sight for the “Golden Age” of Rogue Treatment Profiteers?
W
e are all familiar with the horrific stats:
n “Drug overdoses killed about 72,000 Americans last year, a record number that reflects a rise of around 10 percent, according to new preliminary estimates from the Centers for Disease Control” (Sanger-Katz, 2018). n “The death toll [from opioids] is higher than the peak yearly death totals from HIV, car crashes, or gun deaths” (Sanger-Katz, 2018). Clearly, it is going to take a monumental effort by the medical community, public health agencies, and federal and state governments to climb out of this country’s worst-ever drug epidemic. This is a huge challenge in and of itself. In the process, we cannot allow bad or ineffective actors make the problem even worse. This was the overriding message from the Subcommittee on Oversight and Investigations which held hearings “Examining Advertising and Marketing Practices within the Substance Use Treatment Industry” on July 24, 2018. Previously, this Subcommittee learned about patient-brokers who profit from recruiting patients with opioid addiction and sending them to dubious treatment centers in other states. Before we look at the testimony provided to the Subcommittee on this latest occasion, let us wind the clock back just a few years to get a better handle on the setup for some of these nefarious practices. This is what Rohit Chopra, Commissioner of the Federal Trade Commission, included in a letter to the subcommittee:
When the foreclosure crisis devastated neighborhoods across the country, there were many actors who saw big opportunities for profit. When it comes to the devastation wrought by the opioid crisis, it is déjà vu. The opioid epidemic has led to a boom in the for-profit substance use treatment industry. Billions of dollars of capital have been flowing into the sector from Wall Street, primarily from private equity investors. Many nonprofit treatment centers report that investors are seeking to buy them in order to convert them to a for-profit model. A decade ago, 60 percent of treatment centers were nonprofit; today, 60 percent are for-profit. . . . While private equity and other investments into the industry can support capacity expansion and facility upgrades, I am concerned that investors’ financial incentives may create the conditions for unfair or deceptive practices to flourish. Bad actors employ these practices to lure in patients and soak their insurers with excessive bills, rather than setting them on the road to recovery. 4
Counselor | October 2018
. . . As Congress continues its work to investigate advertising and marketing practices in this industry, it must carefully look at how the billions of dollars of new investment in the sector may be spawning scams that harvest profits from patients and their families. Congress should closely examine incentive compensation practices for employees and operators of treatment centers, as well as financial conflicts of interest with other firms. Importantly, we must work to crack down on illegal lead generation practices, both online and offline, for-profit and nonprofit. Too many firms are looking to profit off the pain of families dealing with addiction. In the absence of vigorous enforcement and sensible safeguards, the opioid crisis will inflict even more financial, physical, and emotional damage throughout our country (Chopra, 2018). Turning its attention specifically to advertising and marketing practices in the industry, the Subcommittee cited reports of aggressive advertising and marketing strategies by treatment facilities— such as websites and 1-800 numbers—that do not clearly disclose who patients are contacting or to where they are being referred. Some facilities also try to lure in patients with promises of luxurious treatment, including daily yoga sessions and free housing. More damning is that the Subcommittee heard of call centers, for example, that sell customer referrals to treatment providers. Some also hide the fact that they are making referrals for a fee, or that the call center is owned by the same company that owns the treatment center. One of the themes that has emerged in the Subcommittee’s one-year examination of the opioid crisis is that families need Continued on page 20
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CCAPP
Sober-Living Regulations throughout the Nation, Part I Lillie W. Singh, Esq.
W
hile there are a plethora of rules and regulations that govern substance use disorder (SUD) treatment programs, until recently there have been few federal or state laws affecting sober living and recovery residences. Some municipalities have attempted to limit the proliferation of sober living homes through zoning laws and rigorous safety standards, but states themselves have been slow to attempt to regulate this growing industry. SUD treatment centers—including inpatient rehabilitation programs, outpatient programs, medically monitored detoxification, and halfway houses providing clinical services—are usually required by state law to receive licensure from a state regulatory authority to operate. Facilities dispensing controlled substances, like many medication-assisted treatment (MAT) programs for opioid addiction, require additional federal licensure to operate. The licensure process typically requires that SUD treatment facilities follow detailed regulations and departmental guidelines, provide proof of legal compliance, submit to inspections by department officials, guarantee certain rights for clients and conditions for operations, and pay fees for initial licensure registrations and renewals. Licensed treatment facilities are subject to constant oversight and scrutiny from state and local governmental agencies, and may have their licenses suspended, modified, or revoked for regulatory infractions and legal violations. Meanwhile, sober-living residences, also known as “recovery residences” or “drug- and alcohol-free housing,” are designed to house and support the recovery of individuals who are working on treating their SUDs. These sober-living facilities have been traditionally thought of as being “off limits” to state and local regulations. This is because sober-living facilities do not offer treatment services and are instead groups of individuals, with legally recognized disabilities, living together as a single household or unit. As a result, their circumstances result in federal legal protections, including provisions under the Americans with Disabilities Act (ADA; 1990) and Fair Housing Act (FHA; 1968), which have been interpreted by courts to allow residents to live as a family without undue intervention from federal, state, or local governments. Many municipalities have tried to impose zoning ordinances and fireand safety-related regulations that would tend to limit the ability of sober-living facilities to operate in their residential neighborhoods, but there were few statewide efforts to regulate sober-living facilities in light of ADA and FHA protections. Recently, however, some states have been passing legislation that challenges this premise. Certain states have taken an approach whereby they offer “voluntary” licensure or certification of sober-living residences, but only those licensed or certified 6
Counselor | October 2018
residences may obtain referrals from licensed treatment facilities, state-run agencies, and/or government-funded programs. Laws like this—in place in Florida, Maryland, Massachusetts, Missouri, and Rhode Island, and passed in Pennsylvania—may have the effect of requiring licensure to operate, even though the laws say that such state approval is voluntary. Meanwhile, other states like Arizona, New Jersey, and Utah have been even more aggressive in setting up mandatory licensure for all soberliving facilities in the state. Many stakeholders in the recovery-residence industry believe the voluntary licensure regulations strike the right balance between protecting sober-living residents and avoiding conflict with federal law. Andrew Martin, COO of the Behavioral Health Association of Providers (BHAP), has indicated that the SUD treatment industry “needs to support our lawmakers in passing legislation that will improve and benefit our industry, and deliver more people who are suffering from addiction, and other behavioral health problems, into wellness and recovery” (A. Martin, personal communication, June 15, 2018). Fred Way, executive director at the Pennsylvania Association of Recovery Residences (PARR) and founding member of the National Alliance of Recovery Residences (NARR), stated that he believes certification programs, like the one in development in Pennsylvania, are “absolutely a good development” (F. Way, personal communication, June 15, 2018). Mr. Way believes that most sober-living operators want to operate correctly and provide the best recovery experience for residents, and they need some oversight to accomplish those goals. Mr. Way posits that certification standards in every state—along with funding programs for recovery residences to open and operate—would go a long way in the fight against SUDs and in preventing wrongdoing in the recovery-residence industry. The National Council
CCAPP for Behavioral Health (NCBH) has issued its own recommendations that states consider legislation that require recovery residences to be voluntarily certified and that incentivize referrals and funding to certified recovery homes (NCBH/NARR, 2018). Industry leaders appear to agree that states should not attempt to create licensure and certification programs and standards on their own. Pete Nielsen, CEO of the California Consortium of Addiction Programs and Professionals (CCAPP) supports a “public-private relationship where the state allows a nongovernmental entity to regulate sober living,” and points out the precedent for this model whereby many states allow private organizations to certify drug and alcohol counselors (P. Nielsen, personal communication, June 15, 2018). He believes that states should use NARR-related standards and procedures, including the complaint processes and inspections done by NARR affiliates to certify sober homes. The NCBH believes that the “long-tested standards” set forth by NARR, its local affiliates, and the Oxford House Model can serve as models for the state licensure and certification requirements. According to the NCBH, using these model guidelines can help reduce the administrative effort needed to create standards on the state or local level (NCBH/NARR, 2018). Mr. Way agrees that states are wise to accept input from organizations like PARR, which has been certifying recovery residences since 2011, in developing their own licensure programs (F. Way, personal communication, June 15, 2018). Meanwhile, stakeholders in the industry remain still concerned about the effects of mandatory licensure programs. David M. Sheridan, president of NARR, believes that the goals of consumer protection are valid and that states have an important role to play in setting standards for sober living, but that many legislators do not consider the implications for access in their regulatory proposals (D. Sheridan, personal communication, June 15, 2018). Licensure standards cannot be so onerous that it is prohibitively expensive to comply, and affordable residences are forced to close. “States’ proposals for regulating recovery housing often parallel clinical treatment standards, and treat recovery housing like it is residential treatment, which it is not. Those industries can pass through costs
to consumers and insurance companies, but this area is different because it deals with housing,” Mr. Sheridan has observed (D. Sheridan, personal communication, June 15, 2018). Similarly, Mr. Martin has concerns about the encumbrances for recovery residences posed by regulatory fees, licensures, and compliance audits. Industry experts are concerned that this will force sober-living residences to raise costs or to close, which would create serious accessibility issues for the individuals who need this supportive housing. The NCBH has also indicated that if certification programs become mandatory, that could raise significant, fair-housing issues and that states like Massachusetts, when considering whether to establish mandatory or voluntary programs, have found that mandatory licensure or equivalent regulations could violate the FHA and ADA. Mr. Nielsen and CCAPP share those concerns regarding federal law, and fear mandatory licensure would be cost prohibitive to operators and residents alike, as it would require raising housing fees to comply (P. Nielsen, personal communication, June 15, 2018). Given these concerns, even though NARR representatives would like to see widespread standards, they are wary of mandatory licensure programs—especially when there is not government funding provided to support recovery houses meeting
the standards. Some jurisdictions with certification programs, like Massachusetts, have used state dollars to support recovery housing specifically, which Mr. Sheridan says is crucial to maintain access while imposing regulation. NARR wants to see standards implemented and enforced in the industry but “we do not want to crush low-cost capacity when we already need more of it” (D. Sheridan, personal communication, June 15, 2018). Accordingly, as federal and state legislators consider both voluntary and mandatory licensure and/or certification, stakeholders urge lawmakers to consider appropriately funding these programs through substance abuse prevention and treatment block grants, state grant programs, and other funding initiatives. It remains to be seen whether adequate funding could alleviate some of the concerns related to access and reasonable accommodation that arise under federal laws like the FHA and ADA. Operators of sober-living residences, and the treatment facilities that refer patients to them, must stay informed of applicable rules and regulations. It is important for professionals in the SUD treatment industry to understand the federal protections in place for sober-living residences, the recent state legislation aimed at regulating recovery residences, and the current debate over the legal validity of these regulations.
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CCAPP Federal Protections for SoberLiving Residences
Federal laws, including the FHA and ADA, prevent discriminatory housing practices against individuals with disabilities. The FHA prohibits discrimination in housing based on legally protected characteristics like disability, race, color, sex, religion, or national origin. Under the FHA, state and local governments are prohibited from enacting or enforcing land use or zoning laws that discriminate against persons because of a legally protected characteristic. Meanwhile, the ADA prohibits discrimination against individuals with disabilities in all areas of public life, including employment, education, transportation, and public accommodations. Both the FHA and ADA require public entities to grant “reasonable accommodations” as necessary to provide equal housing opportunities to individuals with disabilities (Fair Housing Act, 1968; Americans with Disabilities Act, 1990). Alcohol and substance abuse addiction is a cognizable “disability” for the purposes of both the FHA and ADA. As such, both the FHA and ADA prevent laws and practices that discriminate against individuals with SUDs, who are considered a “protected class.” As a general matter, a state government could not, for example, prohibit SUD treatment centers from operating in circumstances where they allowed treatment facilities for other conditions; a municipality could not create a public-housing program that excluded individuals who struggled with alcoholism. In light of the FHA and ADA, states like California have adopted their own laws that spelled out prohibitions against trying to regulate any group of six or fewer individuals trying to live together in a family-like unit through permitting or other ordinances that would not apply to other single-family homes. In addition, some legal practitioners in the field, like attorney Kim Savage, assert that sober-living homes are subject to federal and state privacy protections along with the protections under the FHA and ADA (Savage, 1998). For example, the Fourth Amendment to the United States Constitution protects “[t]he right of people to be secure in their persons, houses, papers, and effects, against unreasonable searches and seizures” (US 8
Counselor | October 2018
Const. amend. IV). Most states also have laws that protect citizens’ rights to not to be disturbed in their private affairs or have their homes invaded without legal authority. Ms. Savage has argued that unrelated individuals inhabiting sober-living homes have the right to reside together in a group setting without intervention from the government pursuant to privacy laws at the federal and state levels. She notes that many courts have agreed that individuals residing together in a family-like way or as a single housekeeping unit constitute a family for purposes of land use and zoning regulations (Savage, 1998). Yet, even where there are both federal and state protections in place, local legislators have tried to create laws that end up discriminating against recovering addicts. Laws may be either “facially discriminatory,” where a law directly targets a protected class, or laws may be discriminatory “as applied,” where the law has the effect of hurting a specific group. While the exact tests courts apply when evaluating an allegedly discriminatory law vary by jurisdiction, in general courts have held that laws are allowed to treat a protected class differently if the restriction is intended to benefit the protected group or responds to legitimate safety concerns raised by affected individuals. Facially discriminatory laws will usually be challenged in court, if they pass in the first place, which leads to expensive and drawn-out litigation where the government bears the burden of proof to show that the laws have legitimate purposes and do not harm protected classes. More common are laws that purport to affect everyone the same but, as applied, have disparate effects for protected classes or were enacted with a discriminatory intent against a protected class. These laws may also be challenged in court, but they are considered more difficult cases for would-be plaintiffs to prove. In these cases, the affected parties show that the laws create a discriminatory, “disparate effect” against their protected class, and then it is up to the government to prove a nondiscriminatory reason for the law. The government must also defend its refusal to make a reasonable accommodation for the aggrieved parties if they sought an exception to the law as applied to them. Many zoning regulations, which tried to prohibit sober-living facilities from
operating within certain residential areas by prohibiting group housing in general, have been challenged on the basis “as applied.” In addition, laws that required sober-living residences to abide by strict requirements were challenged as violations of the ADA and FHA. These laws were often held to be invalid because they prevented recovering addicts from obtaining the housing they needed to deal with their disabilities, and had the effect of harming a protected class. Some sober-living operators who challenged these laws in court were awarded damages against the cities or other government entities that tried to prevent them from operating. The costs of defending these laws in the court of public opinion, litigating challenges brought by operators in civil suits, and potentially paying damages to aggrieved parties deterred many state and local municipalities from even attempting to put zoning laws affecting sober-living houses in place. Nonetheless, as described in the next part of this column, many states have recently tried to regulate sober-living facilities through statewide licensure and certification requirements. c About the Author Lillie W. Singh, Esq., received her juris doctor from the Stanford Law School in 2008. She has been named a rising star in health care by Super Lawyers Magazine. She has given talks to lawyers and health care professionals about patient privacy under HIPAA and state laws, and has written articles on many issues facing health care providers, addiction treatment center operators, and sober-living programs. Disclaimer: The information provided in this article is for educational purposes only. It is not intended to provide legal advice. It is advised to consult qualified legal counsel before beginning or continuing operations as a sober living facility.
References Americans with Disabilities Act of 1990, Pub. L. No. 101– 336, § 104 Stat. 328 (1990) Fair Housing Act of 1968, 42 U.S.C. § 3601–3619 National Council for Behavioral Health (NCBH), National Alliance for Recovery Residences (NARR). (2018). Building recovery: State policy guide for supporting recovery housing. Retrieved from https://www.thenationalcouncil.org/ wp-content/uploads/2018/05/18_Recovery-HousingToolkit_5.3.2018.pdf Savage, K. (1998). Fair housing law issues in land use and zoning. Retrieved from http://www.21elements.com/ Download-document/441-Definition-of-FamilySupplemental-Resource.html US Const. amend. IV.
NACOA
When Words Are Not Enough: Why Experiential Forms of Healing Are Desirable in Treating Relational Trauma Tian Dayton, PhD, TEP
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e need to feel the stories of our lives in order to heal them, but trauma is all about not feeling. Even asking the question, “Can you tell me about your trauma?” can be befuddling, if not disturbing, for ACoAs who have learned to rationalize and deny our pain and confusion in order to stay connected to the families we love and need.
When we reduce therapy to only words— for example, when we ask first responders to tell us about the horror of watching groups of people lock arms on the top of a building and leap to their deaths, or recollect the screams of those buried in rubble waiting to be rescued—we ask too much, and it is too painful, freakish, and shocking to put into words. And then, over the next several months within the lives of these first responders, divorce rates rise, alcohol and drug addiction shoots up, and cases of spousal abuse become commonplace—the terror and pain are locked in the part of the brain-body that words do not reach. Similarly, when we ask clients to tell us all about their experiences of being sexually or physically abused, neglected, or frightened by frequent scenes of drunkenness or rage, we are asking them to move past their own primitive, defensive barriers and to feel feelings they long ago shut down. Debriefing and describing these experiences in words is neither efficient nor effective because, in spite of their profound and disturbing impact, many of us caught in these experiences have sometimes barely let ourselves believe the events actually happened. When we are facing danger, whether that danger is a charging elephant or a drunk, raging parent, the thinking mind shuts down and our feelings of fear make
the limbic system rev up. We are supercharged with extra adrenaline and blood flow to enable us to flee for safety or stand and fight. When we can do neither, we freeze and dissociate—we stand there in body, but disappear in mind. Then years or even decades later, when a well-dressed therapist in a nicely furnished office asks us to reenter those disparate remnants of personal experience and drag them from their hidden world into comprehensible, well-ordered sentences, we feel anxious and put on the spot. What are we supposed to say? It was so long ago, and it feels so very far away. And when asked how we felt at the time, we just do not know. Maybe our stomachs get queasy, we tense up, and we want to leave the room, but we have no idea why. We appear to be resisting the therapist’s question, but in truth we are just very much afraid of the feelings that may come up and overwhelm us. These are feelings we never made sense of to begin with, firstly because that part
of our brains was temporarily offline, and secondly because for us as children in alcoholic homes, the people we would go to for reality checks, comfort, and to help us find words to understand the pain we were in and describe it, are the very people who were hurting us and robbing us of a sense of safety to begin with. If this pain were repaired on the spot, it could relieve us as children, allow us to reconnect with ourselves and our parents, and actually build understanding and resilience. When it is not repaired, the pain goes underground. The days, months, and years of broken promises, drunken scenes, and the mood swings in the household and the parents themselves create deep pain, confusion, and resentment for children who learn to rewrite reality to make it more “manageable.” Later, as adults, our personal narrative can have big, blank spots in it. It is as if parts of us were strewn all over a room, but that room is too dark for us to see what is there. Entering that room, www.counselormagazine.com
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NACOA gathering up those pieces of our personal experiences, and stringing them into a meaningful and understandable whole— allowing the shards of self to float back and nestle themselves into the framework of our life script or narrative—is the work of therapy. To accomplish this, we need forms of therapy that allow us to feel, sense, and grope our way along the associative mind-body pathways that will lead us toward these forgotten fragments.
Why Traumatizing Experiences Remain Nonconscious
When the thinking mind or prefrontal cortex is not doing its job of elevating experience to a conscious level, converting it into language, and making sense of it, then frightening or traumatic experiences do not get processed and recorded in the same way as ordinary experiences. This inability to tell a clear trauma story, in my opinion, can also look like memory loss around traumatic events. Herein lies a danger in trauma resolution: clients may either create stories that seem to fit the profile expected of them, or they may accept another person’s interpretation of events because they cannot come up with a satisfactory one of their own. Another danger is that clients may jump at the opportunity to get out of their moment of reliving—which is so uncomfortable and has so long been defended against—by forcing themselves to respond to questions that are
actually pulling them out of those incredibly tender moments of remembering and reliving; questions that are not really helping them to stay in the moment and with themselves. The real healing, however, is in tolerating the reliving, the discomfort, the confusion, the fear, and the anxiety we may not have been able to process at the time, which can be triggering for therapists and group members. Going for words too soon can actually collide with clients’ wishes to avoid feeling the pain that these moments of reliving bring up. Approaches to therapy that allow the body (as well as the mind) to stumble down an associative path that leads to truth tell a more complete, compassionate, and full version of the trauma narrative. We need to use therapies that allow clients to feel safe during their process of remembering and reliving; if we can do this, they will be able to reknit the fragments of forgotten experience back together into a coherent whole themselves. This can even occur in one-to-one therapy if therapists can understand the human response to trauma and how to heal it. I use role-playing because it stimulates and simulates the family cluster that needs to be made conscious. Talking to rather than about, even if it is simply an empty chair representing someone else or a part of the self, invites a spontaneous connection to emerge naturally. We reach out and get to know our depressed selves; we make connections with
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Counselor | October 2018
the inner child, whose creativity we may have shut down; we befriend the lonely adolescents, encourage the inner adults, or invite the carefree selves we have lost touch with to come back to us. All of this direct and targeted interaction is self-referential; it emerges spontaneously from a simple role-play that can trigger a flood of words because we are free to fulfill that inner hunger to reconnect, to express ourselves, to be seen and heard, and to find our own voice within a relational context. Then in psychodrama we reverse roles so we can get a felt sense of what it is like to see ourselves from the position of the other. Or we talk from the role of our child selves back to our adult selves. Or we stand in the shoes of those to whom we have given so much power and experience their humanity as well as our own. In this way clients spontaneously warm up to their own story—it is theirs, told in their voices and the voices of those they care about, with all of the emotion, action, and nuance that is particular to them, to this relationship, this context, and this scene. Untreated ACoA pain can present itself in adulthood as a posttraumatic stress reaction in which unprocessed relational pain from childhood is surfacing and being lived out in adult relationships. When ACoAs grow up, partner, and parent, the deep connection this requires can act as a trigger for unprocessed, childhood pain. This is also the kind of pain that, if left untreated, can lead to self-medication, which is why many ACoAs have trouble with their own process addictions or addiction to drugs and/or alcohol. Twelve Step programs are a powerful first step in getting to know more about the disease of alcohol and its far-reaching impact. To learn more about the effects of adverse childhood experiences and to gain guidance on how you or your community can begin to heal, visit www.nacoa.org. c Tian Dayton, PhD, TEP, is the author of sixteen books, including The ACoA Trauma Syndrome, Emotional Sobriety, Trauma and Addiction, Forgiving and Moving On, and The Living Stage. In addition, she has developed a model for using sociometry and psychodrama to resolve issues related to relationship trauma repair. Dr. Dayton is a boardcertified trainer in psychodrama, sociometry, and group psychotherapy and is the director of The New York Psychodrama Training Institute.
OPINION
Intimacy in Counseling D. John Dyben, DHSc, MCAP, CMHP
O
pen your favorite academic search engine and query “intimacy in counseling” or some variation on that theme. The vast majority of articles, chapters, and books you will find referenced address how counselors help patients deal with intimacy in their relationships. This is certainly how it should be, given the importance of the topic in our field. However, there is another aspect of intimacy in counseling that is also highly relevant yet less frequently discussed: intimacy in counseling and supervisory relationships. Perhaps one reason for this paucity in literature is that the term “intimacy” is often associated with romantic or sexual relationships that would be inappropriate in a counseling or supervising relationship. A more comfortable and commonly used frame of reference is the concept of “therapeutic rapport.”
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OPINION Therapeutic rapport is a broadly understood paradigm for the level of connection and openness in a counseling relationship that facilitates healing and growth in patients. Similarly, in supervisory relationships with students or other new counselors, healthy rapport serves to facilitate learning and skill development. Having spent many years as a therapist and clinical supervisor, I have found that the concept of therapeutic rapport is one that is conceptualized in many different ways and that my own understanding of it has changed over time. My experience is that newer counselors having a difficult time setting boundaries with patients will often tell me that they do not want to “hurt their therapeutic rapport.” Another pitfall is overuse of self-disclosure in an effort to “develop therapeutic rapport.’’ It is sometimes difficult to quantify how to best develop healthy and ethical therapeutic rapport, but I have come to believe that in order to understand it, we must examine the very real aspect of intimacy that is a part of it. Sullivan (1993) suggests that intimacy involves four qualities: proximity, mutuality, trust, and selfdisclosure. Seasoned counselors will read those qualities and either see four areas of potential danger or four areas of immense opportunity, depending on their mindset at that moment. Let us consider each, examining some threats and opportunities in both counseling and supervision.
Proximity
Whether through physical closeness in an office or through telemedicine, the practice of counseling and clinical supervision alike will involve regular times in close proximity. Prior to the last decade or so, “proximity” has been a relatively static term; it simply meant the degree of physical closeness one person or object had to another. Today, the proliferation of social media into our national and global psyche has complicated that term. Particularly when working with individuals who have grown up with social media as the norm, counselors and supervisors must consider how both physical and virtual proximity impact the dynamics of the professional relationship. 12
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Awareness of how proximity effects patients or supervisees comes as the result of professional counselors assuming nothing and asking regular questions. At the onset of professional relationships, counselors are well advised to initiate a discussion about proximity and how patients or students see their own needs in this area. Throughout the process, especially when there seems to be an unexplained strain in the professional relationship, having these conversations is well advised.
Proximity, mutuality, trust, and self-disclosure: these are four complicated elements of intimacy, but are worth a close and ongoing examination if we are going to develop healthy, effective rapport with patients and supervisees. Also, given the dynamics of virtual proximity in today’s culture, great care should be taken in considering to “follow” or “friend” patients online. This act is construed by many as equal to any other face-to-face friendship and one may unwittingly enter into an inappropriate dual relationship.
Mutuality
Merriam-Webster defines “mutuality” as “a sharing of sentiments” (2018). In nonprofessional relationships this is often an apt descriptor of an important quality of intimacy. Though intimate relationships never require people to feel the same about everything, a general sharing of sentiments about significant issues is important. In clinical and supervisory relationships, mutuality is much more about having a shared direction and end-goal for the relationship. As counselors, our end goal is to facilitate health and well-being in our patients even if their values are contrary to our own. We need
not share sentiments; we need to share goals. As supervisors, our goal is not to make counselors who will think like us. Our goal is to protect patients and enhance the science and art of counseling through a reflective, tutorial process. In professional relationships it is the counselors’ responsibility to clarify this difference in mutuality and to clearly establish the process. This can be uncomfortable when patients or supervisees are primarily seeking validation for the professional relationship. Though it can be tempting to take the easy route of simply providing warm feelings for patients and supervisees, our job is to help facilitate movement towards goals and this must not be lost.
Trust
In any relationship, trust involves two important principles: fidelity and veracity. Fidelity is about keeping promises and veracity is about telling the truth. When people ask, “Do you trust me?” they are asking, “Do you believe that I will do what I say and that I will say what I mean?” In counseling and supervisory relationships, the question of trust is key to establishing an environment of safety. It is this safety that allows for and cultivates vulnerability, which is necessary for any genuine growth to occur. The great difficulty with trust is establishing and nourishing it. The potential pitfall of trust is overdependence on this trust. I have often been asked by supervisees, “How do I get patients to trust me?” This answer is: be trustworthy. In fact, I believe the question “Do you trust me?” is generally the wrong question to ask in any relationship. The better question is “Am I being trustworthy?” When we ask ourselves, our patients, and our supervisees this question, we potentially gain important and actionable information. This is only insofar as we are genuine in this question and we seek to be open to growth and change at ourselves at all times. The potential pitfall with trust is that it can cause overreliance with anyone involved. Patients may believe that their counselors have all the answers for them and develop unhealthy dependence.
OPINION Students and supervisees may experience this as well. In clinical supervision, supervisors may have so much trust in supervisees’ natural abilities that they may provide less oversight than is needed. It is important to remember to keep trust in its professional realm. When we set clear boundaries and expectations, we can simply ask, “Am I doing what I say and saying what I mean?”
Self-Disclosure
As an educator, I have often told students that they should never use self-disclosure as a therapeutic tool for at least their first five years as credentialed counselors. This is meant to be a bit tongue-in-cheek, but it has an element of seriousness to it. When I was a little boy, I remember a teacher once told me that “intimacy” meant “into-me-you-see.” Many decades later I see intimacy differently, but I still believe that this teacher’s idea has some merit to at least part of the equation. There is a power to selfdisclosure, and it tends to draw people
to each other. Appropriate use of selfdisclosure can sometimes be a catalyst to help patients or students begin to consider moving into trust. However, there are many potential pitfalls to self-disclosure—too many, in fact, for this article. The most significant problem with utilizing self-disclosure is that it has the potential of turning the focus from patients or students to professional counselors, effectively losing the point of the entire process. Counselors at all levels should use self-disclosure like hot pepper—sparingly, with forethought, and everyone should know about it. The question “Am I sharing this for my patient or am I doing this for me?” should be at the forefront of any self-disclosure.
Conclusion
Proximity, mutuality, trust, and selfdisclosure: these are four complicated elements of intimacy, but are worth a close and ongoing examination if we are going to develop healthy, effective rapport with patients and supervisees. As a counselor looking to be effective and
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ethical in these areas, I try to remember that no one can see the spinach in their own teeth. The development of intimacy in a context of clinical excellence will always require intention of action, openness to invite colleagues to help us to see what we cannot see ourselves, and a willingness at all times to make course corrections in the best interest of our patients. c About the Author D. John Dyben, DHSc, MCAP, CMHP, is the CCO at Origins Behavioral HealthCare. His experience as a teacher, counselor, executive clinical supervisor, and ordained pastor informs his therapeutic approach to integrating clinical intervention approaches with individual and family needs, as well as continuity of care. He is a certified master addiction professional, internationally certified alcohol and drug counselor, substance abuse professional, and certified MBTI practitioner.
References Merriam-Webster. (2018). Mutuality. Retrieved from https://www.merriam-webster.com/dictionary/ mutuality Sullivan, K. A. (1993). Self-disclosure, separation, and students: Intimacy in the clinical relationship. Indiana Law Review, 27, 115–56.
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WELLNESS
Slow Down, You’re Going Too Fast, Part II John Newport, PhD
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n the first installment of this series I reviewed contributing factors to the pressure-cooker lifestyles that far too many working Americans accept as the norm. These include a corporate ethos that embraces the aggressive pursuit of profit—while increasingly viewing workers as mere tools of production—together with the 24/7 encroachment of work-related matters into our personal lives via e-mails and other electronic intrusions. Added to this is the practice of many companies of routinely laying off thousands of workers when earnings fall below projected targets. That installment also discussed the price we pay, both individually and collectively, in terms of declining quality of life, deteriorating health, and erosion of core values that have historically promoted living in balance with a commitment to caring for others. This second and final installment will provide pointers for freeing ourselves from the fast lane while imbuing our lives with deeper levels of joy and fulfillment, together with truly compassionate relations with those around us. Root Causes
I personally believe that a major causative factor underlying the increasingly depersonalized and frenetic pace of living foisted upon us is a growing oversecularization of our society. This has ushered in a disturbing decline of traditional values that placed a premium on promoting wholesome individual, family, and community relations designed to promote the common good and dignity of all. Unfortunately, in many spheres our contemporary society appears to embrace a “winner take all” ethos governed by the law of the jungle. This serves to pit us against each other while precipitating further erosion of our innate predisposition toward caring and compassion. All of this perpetuates a growing sense of isolation and lack of purpose in the lives of many Americans, as underscored by the rising incidence of suicide over recent decades (Friedman, 2018; Scutti, 2018).
Reinventing Ourselves as Human Beings
Years ago, when we lived in Washington, my wife and I hosted a monthly Buddhist studies group led by a Zen master. Underscoring our need to slow down and bring our lives into balance, one of his favorite sayings was, “Don’t just do 14
Counselor | October 2018
Thich Nhat Hanh (in black) at Hue City, Vietnam
something, sit there!” An underlying theme of his teachings was allowing ourselves to emerge as genuine human beings, rather than human doings. We reap abundant rewards when we make a concerted effort to transform our lives and take ourselves off the fast track. Potential benefits include enjoying a renewed sense of vitality, equanimity, and purpose in life while concurrently enjoying improved health and well-being at the physical, mental-emotional, and spiritual levels. For people in recovery, these qualitative improvements translate into dramatically reduced risk of relapse and a deepened commitment to recovery. Presented next are several pointers you may wish to consider if you truly desire to take yourself out of the fast lane. This is only a sampling; I am sure you can come up with numerous ideas of your own to assist in making the transition.
Take a Midlife Inventory
From time to time we need to pull back and do some serious reflecting on where we are in life and it lines up with where we really want to be. An integral component of this process is both identifying and committing to what is truly important to us. For example, suppose you are a highly successful (in conventional terms) corporate executive, pulling in an enviable sixfigure income while often working over sixty hours per week. Ask yourself: Is this truly the way I want to live my life and, if
WELLNESS not, what is missing? What are my true passions—irrespective of opportunities for financial reward—and does my present lifestyle allow me to fully pursue these passions? What are my core intrinsic values, and am I currently living my life in alignment with these values? What changes would I need to make to truly live in accordance with my values? If I were lying on my deathbed, how would I complete the following statement: “I wish I spent more of my time doing ___.”
Deepen Your Relationship with Your Higher Power
As a consequence of the oversecularization that permeates our culture, far too many of us fail to make a heartfelt effort to commune with our higher power on a daily basis. When we earnestly choose to seek divine guidance, we gain invaluable insight in clarifying what is truly important to us, and moving our lives into closer alignment with these aspirations.
Reacquaint Yourself with the Wonders of Nature
When was the last time you took a leisurely stroll through nature, savoring the wonder and beauty that surrounds you? Blessed by living in the beautiful Sonoran desert, I begin each morning with a long walk along a desert trail, attuning myself to the various cacti; the seasonal flowers; the many birds, reptiles, and other animals I encounter; and the majesty of the nearby mountains. I find this to be both enlivening and invigorating, as well as an opportunity to release any discordant thoughts I may be running through my head. If you thrive on being totally immersed in the serenity of nature, you may want to indulge in some creative brainstorming concerning how you might manage to move to a more pristine locale. The advent of telecommuting and teleconsulting opens up whole new vistas for making a livelihood while living where you truly want to live.
Embrace Voluntary Simplicity
As an example of voluntary simplicity, I love the Slow Food Movement, which originated in Italy with an initial objective, I believe, of encouraging families to use mealtimes as an opportunity to
truly connect with each other, while savoring the experience of enjoying a delicious meal together (Slow Food USA, 2018). Core objectives of the movement include “taking pleasure in the process of cooking, eating, and sharing meals with others” as well as “promoting local artisans, local farmers, and local flavors through regional events, social gatherings, and farmer’s markets” (Slow Food USA, 2018).
We reap abundant rewards when we make a concerted effort to transform our lives and take ourselves off the fast track. Tune in to Your Inner Buddha
Having followed a blended approach to spirituality throughout most of my adult life, I embrace many traditions and precepts of Buddhism. For decades I have been particularly inspired by the compassionate, from-the-heart teachings of Thich Nhat Hanh, a Vietnamese Monk and peace activist during the Vietnam War, who was nominated by Martin Luther King Jr. for a Nobel Peace Prize. My favorite book by Thich Nhat Hanh, known by his followers as “Thay,” is a small treatise titled No Mud, No Lotus: The Art of Transforming Suffering (2014) which I recently completed. In this marvelous book, he teaches us how to gracefully embrace and transform our suffering, finding true peace and serenity in the midst of the intense turmoil we are surrounded by. Through teaching us to ground ourselves in the present moment through mindful breathing and cultivating a truly compassionate orientation toward ourselves, our suffering, and those around us and across the globe, he provides us with precious tools for attaining and maintaining inner peace and calmness, irrespective of whatever turmoil is going on in the outside world. The wisdom he imparts is truly a powerful antidote to the frenetic, fast-paced environment we
encounter during most of our waking hours. I highly recommend any and all of Thay’s wonderful books. These are just some examples of the growing options for embracing voluntary simplicity to loosen the grip of fastlane living on our lives. If you truly want to simplify your life, you need to carefully consider both the options and the associated trade-offs. Run your dream by the rest of your family and engage in a spirited dialogue. In many cases, the trade-offs may require that you and your family significantly downsize your financial aspirations. As you brainstorm the options together, keep in mind that the bottom line boils down to what kind to life you truly aspire to, and how you can pull together as a team to make it work.
Conclusion
In closing, I hope I have presented you with practical suggestions for loosening the insidious grip of today’s fast-paced and increasingly depersonalized environment on both your lives and the lives of your clients. I also hope that some of you may be inspired to undertake an indepth inventory, focusing on where you are at this juncture in your life and how this stacks up in terms of where you really want to be. I also hope that some of you choose to use this as a springboard for freeing yourself from the fast lane and creating a truly fulfilling life. Until next time—to your health! c About the Author John Newport, PhD, is an addiction specialist, writer, and speaker living in Tucson, Arizona. 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.
References Friedman, R. A. (2018). Suicide rates are rising. What should we do about it? The New York Times. Retrieved from https://www.nytimes.com/2018/06/11/opinion/suicide-rates-increase-anthony-bourdain-kate-spade.html Hanh, T. N. (2014). No mud, No lotus: The art of transforming suffering. Berkeley, CA: Parallax Press. Scutti, S. (2018). US suicide rates increased more than 25 percent since 1999, CDC says. Retrieved from https:// www.cnn.com/2018/06/07/health/suicide-report-cdc/ index.html Slow Food USA. (2018). History. Retrieved from https:// www.slowfoodusa.org/history
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TOPICS IN BEHAVIORAL HEALTH CARE
The Benefits of Gratitude Dennis C. Daley, PhD
T
he field of behavioral health has expanded the focus beyond illness and suffering, and is directing more attention to positivity and well-being. Positive psychology has developed interventions to help individuals decrease negative emotions and increase positive emotions, enhance relationships, engage in meaningful activities and work, and build upon personal strengths (Fredrickson, 2009; Peterson, 2006; Seligman, 2012). Positive psychiatry is also focusing on ways to enhance well-being, increase positive emotions, and improve psychological strengths in addition to treating mental illness and reducing suffering (Jeste & Palmer, 2015). There is a growing body of research, clinical, recovery, and self-improvement literature on altruism, compassion, empathy, forgiveness, gratitude, happiness, love, mindfulness, posttraumatic growth, and resilience. This includes tools for professionals that can be used in work with individuals who have psychiatric or addictive disorders.
This article focuses on gratitude. I chose this topic as a result of recent experiences that were meaningful and powerful for me, for which I am grateful. The first was attending and speaking at a graduation event by Gaudenzia, a large addiction treatment system. Individuals at this event had sustained at least one year of continuous recovery, and all were integrated back with their families and communities. During the celebration, recovering individuals briefly made statements, most of which included an expression of genuine gratitude to their families, friends, counselors, treatment programs, and God. It rekindled in me my deep gratitude towards colleagues working in the trenches, helping people with severe addictions reclaim their lives, and in many instances helping families heal. I can attest, from decades of providing direct care, that working with addicted individuals and families is demanding, challenging, and humbling work that is reinforced when we see them engage in recovery and make positive self and lifestyle changes. I could see the pride of Gaudenzia staff watching clients receive a personal medallion and certificate commemorating their achievement in sustaining recovery. I could also sense their love and admiration for how these people worked hard to sustain recovery. Family members and friends were grateful to share this event and have their loved ones in recovery back in their lives. 16
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Another experience that triggered deep appreciation and gratitude was spending several days at Faces and Voices of Recovery (FAVOR) in Greenville, South Carolina. FAVOR is an advocacy group that helps individuals and families affected by addiction. FAVOR Greenville operates a recovery center that is a safe place for individuals and family members to learn about addiction and recovery, engage in recovery groups, or meet for individual sessions with a recovery coach or family coach. All coaches are paid professionals or volunteers in long-term recovery who provide face-to-face services on-site or in the community, or by telephone and text messaging. These coaches help individuals find and engage in treatment if needed, and engage in recovery programs at the center and community. I met with recovery coaches individually and in groups, and attended several types of recovery groups for addicted individuals and for families. Individuals engaging in FAVOR services were grateful for the acceptance, love, compassion, and caring received from staff. Staff were grateful for their own long-term recoveries and all the people who helped them, and for having the opportunity to give back to others suffering from addiction or living with addicted loved ones. One staff member saw three addicted individuals in a local hospital emergency department between 9 PM and 3 AM, yet showed up for work at the center the next day. Although he was helping others, he was grateful for this
TOPICS IN BEHAVIORAL HEALTH CARE opportunity and to be part of a center that reaches so many people in need of help. Another staff member talked about her work with families, and invited me to a family support group. What I experienced at meetings with staff and attending recovery meetings was people doing whatever it took to help other people or family members engage in treatment, recovery, or both. And, just as important, was seeing how amily members or individuals with addiction felt and expressed their appreciation and gratitude for the acceptance, help, and support they received.
There are two types of gratitude: personal and transpersonal. Personal gratitude is feeling grateful towards people as the result of a gift they provided to us, a helpful behavior they showed us, or a skill they taught us. Or, this can be feeling grateful for specific people being a part of our lives, such as appreciation for family members, friends, mentors, sponsors, or peers in recovery. We may feel grateful for:
Types of Gratitude
n Love, emotional support, mentoring from another
Gratitude has to do with kindness, generosity, gifts, and the beauty of giving and receiving. Emmons defines gratitude as being thankful for, having readiness to show appreciation for, and returning the kindness received from others (2007, 2013). This kindness results from receiving gifts from other people, or for the exhibited behaviors of others that benefitted us.
n Help with an addiction, mental health issue, or other problem n Help making an important decision n Help with a particular task
n Spiritual, academic, or career guidance n Having a physical, psychological, or creative ability n Having a passion about something in life n Learning or improving skills n Financial assistance or guidance
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n Something personal of value mainly to those receiving the gift, such as a photo, an object of personal beauty, a personal note or letter, an opportunity for an experience (e.g., an event, travel, meeting someone of significance) When we experience gratitude toward other people, we are more likely to do something for them that they may appreciate or feel grateful about. When my wife died of cancer more than thirteen years ago, several friends showed incredible kindness, love, and support during this difficult time in my life. In addition to the deep gratitude I felt towards them, I connected with other friends or colleagues who lost loved ones as a way of giving back what was given to me. The emotional and practical gifts given to me during my bereavement were ones I later shared with others experiencing grief. Transpersonal gratitude is feeling grateful to God or another higher power. Many people in recovery express this type of gratitude at recovery meetings or group treatment sessions.
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TOPICS IN BEHAVIORAL HEALTH CARE Gratitude can also be felt as a result of beauty experienced in nature such as a sunrise; a sunset; a snowstorm; a beautiful mountain, river, or lake; an animal or insect; or other things of beauty. On a recent day in early summer I watched a spectacular sunrise through the trees in my backyard.
Benefits of Gratitude
Research has identified an impressive list of potential benefits of experiencing and expressing gratitude (Emmons, 2013; Lyubomirsky, 2014):
Improved Emotional or Psychological Health
This involves feeling less anxiety, depression, stress, envy, or resentment, and feeling more optimism, joy, happiness, love, or enthusiasm. It is an increase in satisfaction with life.
Physical Health and Habits
This encapsulates feeling healthier with fewer physical symptoms; being less bothered by aches or pains; lowered blood pressure; better sleep; more energy; having a stronger immune system; exercising more; and generally taking better care of health. A study that followed nuns for over six decades found that longevity was higher among nuns with more positive expressions of gratitude, love, hope, and happiness.
Relationships
This includes feeling less lonely and isolated, being more outgoing, making more friends; being more helpful, altruistic, generous, empathic, and compassionate with others; having a stronger bond with friends or romantic partners; and being more likely to forgive other people.
Increasing Gratitude in Daily Life
The following are strategies that can help you increase gratitude in your life. The key is making gratitude expression a habit that you regularly practice so that you appreciate the gifts you have or receive in life, and express your gratefulness to others (Daley & Douaihy, 2010; Emmons, 2013).
Pay Attention to Gifts and/or Blessings You Receive
Be aware of and reflect on positive experiences, interactions, or blessings you receive. I save e-mails, written notes, and 18
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cards people send me in which they express gratitude for something I did for them or gave them.
Minimize or Stop Expressing Ingratitude
Try not to let negative thoughts or feelings get in the way of appreciating things for which you should feel grateful.
Catch Yourself When You Think Nongrateful Thoughts
Challenge any thoughts of ingratitude you have and replace them with more grateful thoughts.
Gratitude has to do with kindness, generosity, gifts, and the beauty of giving and receiving. Share Your Gratitude
Simple expressions of “Thank you” or “I appreciate” go a long way. Others will appreciate hearing these from you.
Do Not Take People in Your Life for Granted
Share your positive feelings of gratitude in what you say or what you do to people you care about. Even small gestures of gratitude can make an impact. There are endless ways to show your gratitude.
Show Gratitude in Your Behaviors
Send an e-mail or text, write a personal note, send a card, give a gift, or do something helpful, kind, or altruistic towards people to whom you feel grateful.
Write
Write in a gratitude journal about people, experiences, or gifts you appreciate or feel grateful about. Or, write a letter to someone towards whom you feel deep gratitude. You can keep this letter to yourself, send it, or read it to them.
Share Your Gratitude Letter
Some people find it meaningful to read or deliver their gratitude letter in person.
Express Your Gratitude through Spiritual Disciplines
Many religions and spiritual practices offer ways to express gratitude such as in prayer, confession, meditation, connecting with others as part of a spiritual fellowship, and being of service to others.
If You Are in Recovery, Give Back to Others
You can do this by serving as a sponsor, peer mentor, or support person in recovery.
Make a Habit to Reflect on Your Blessings
You can do this at the end of each day or week. You simply review the day or week and identify positive emotions, people, or experiences. Feeling grateful and expressing gratitude can easily be incorporated into daily life. Many benefits come from focusing on people, experiences, gifts, or blessings we receive. The challenge is to be aware and not take others and our gifts for granted. Additionally, to go beyond feeling grateful we can share that feeling with others. c About the Author 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.
References Daley, D. C., & Douaihy, D. (2010). Gratitude workbook. Murrysville, PA: Daley Publications. Emmons, R. A. (2007). Thanks! How the new science of gratitude can make you happier. Boston, MA: Houghton-Mifflin. Emmons, R. A. (2013). Gratitude works! A 21-day program for creating emotional prosperity. San Francisco, CA: Jossey-Bass. Fredrickson, B. L. (2009). Positivity: Top-notch research reveals the upward spiral that will change your life. New York, NY: Harmony. Jeste, D. V., & Palmer, B. W. (2015). Positive psychiatry: A clinical handbook. Washington, DC: American Psychiatric Publishing. Lyubomirsky, S. (2014). The myths of happiness: What should make you happy but doesn’t, what shouldn’t make you happy, but does. New York, NY: Penguin Books. Peterson, C. (2006). A primer on positive psychology. New York, NY: Oxford University Press. Seligman, M. E. P. (2012). Flourish: A visionary new understanding of happiness and well-being. New York, NY: Simon & Schuster.
COUNSELOR CONCERNS
The Personal Journey of a Nonalcoholic through the AA Twelve Steps Gerald Shulman, MA, MAC, FACATA
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f you will indulge me, I would like to depart from my usual practice of writing about clinical issues and instead share the journey—mine—of a nonalcoholic within Alcoholics Anonymous (AA). I began my career as a therapist in February of 1962, at a facility previously called Chit-Chat Farms and now called Caron Foundation, founded in 1958. Like other programs at that time, it would not be considered treatment by today’s standards—it provided no assessment, no treatment planning, and no documentation of progress. Group therapy was ten patients sitting in a circle discussing a chapter in the book Alcoholics Anonymous, also known as the “Big Book” (AA World Services, 1984). It was simply complete immersion in the Twelve Steps and philosophy of AA. In spite of what we might assume from the absence of treatment as we would know it today, many of the program’s patients recovered and some became alcoholism counselors. This was not unusual back then because the requirements for becoming an alcoholism counselor were two years of sobriety in AA (and the willingness to work cheap). The fact that such “treatment” worked is not that surprising when we recognize that the patients of the time comprised a very homogenous group of what I lovingly call, “plain, old, simple drunks.” They were employed, unless they lost their jobs because of their drinking; they lived in an intact family, unless they lost their family because of their drinking; and rather than worrying about a GED, the patients had high school diplomas and undergraduate or graduate degrees. If they had co-occurring psychiatric disorders, they were referred to mental health treatment rather
than addiction treatment; if they had major legal problems they ended up in jail or prison rather than addiction treatment. They tended to begin their substance use and develop a diagnosable substance use disorder (SUD) at a later time in their lives than many of today’s patients. Simply stated, these patients—who often manifested a gradual decline into their alcoholism over many years—were “rehabilitatable,” meaning that they were able to return to an earlier level of successful functioning, in contrast to many of today’s patients who are only “habilitatable” because they have no level of earlier successful functioning to which to return. To say that I was a “newbie” when I first started working in the field is giving me much more credit that I deserved. I received a total of about five minutes of education about SUDs in the total of my undergraduate and graduate studies and that was a psychology course instructor mimicking someone. When I began working in treatment I was the only nonalcoholic working in the facility—all the staff members were recovering alcoholics except the cooks, who were still experimenting. The counseling staff had no clinical background, but they were in recovery and able to share their strengths, hopes, and experiences.
Because of the emphasis on AA and the Twelve Steps, it became clear to me that I had to become intimately familiar with the Twelve Steps and the rest of the AA program if I was to be of any value to the program and its patients. Because of the emphasis on AA and the Twelve Steps, it became clear to me that I had to become intimately familiar with the Twelve Steps and the rest of the AA program if I was to be of any value to the program and its patients. There were daily Step lectures for the patients and I attended them as an eager learner. I attended the Sunday AA meeting brought into the facility for the patients by outside AA groups. I began attending Al-Anon and AA meetings in the community at least once a week and actually adopted a Monday-night group as my home group. The group had a commitment at the county jail to conduct a weekly AA meeting that they had not met, so I assumed the commitment, went every week, and helped facilitate a meeting, even though I was neither an alcoholic nor an AA member. I began working the program as if I was an AA member. I have done two written Fourth Steps (“Made a searching and fearless moral inventory of ourselves”; AA World Services, 1984) and taken a Fifth Step (“Admitted to God, to ourselves, and to another human being the exact nature of our wrongs”; AA World Services, 1984) www.counselormagazine.com
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COUNSELOR CONCERNS with a clergyman. I continue to take the Eleventh Step (“Continued to take personal inventory and when we were wrong promptly admitted it”; AA World Services, 1984). So where has all this taken me? In addition to enhancing my ability to cope with my own life and solve problems, one of the results is that I am often mistaken for an AA member when I train. Often participants will approach me during a break and ask, “Are you a friend of Bill?” (i.e., Bill W., the cofounder of AA), a way of asking whether I am an AA member. I view such questions as a complement. I do not think I recognized the impact my AA involvement had on me personally until the following situation occurred. I consider myself a spiritual person rather than a religious one. After fleeing from the Orthodox Judaism in which I was raised, I returned to services in a reform temple during the time I worked at the treatment program. Sporadically attending Friday night services was a young man who I assume suffered from schizophrenia. He would sometimes act in mildly inappropriate ways when noncompliant with his medication and had terrible body odor, but in no way seemed dangerous. A group of women congregants approached the rabbi, saying they were afraid of this man and wanted him banned from services. The rabbi, who was a civil rights activist and an advocate for the disadvantaged of all types, was very conflicted since he served at the pleasure of the congregation. He asked me my opinion and I said, without thinking before replying, “If there is no room for him here, then there is no room for me!” The rabbi, clearly impressed with my response, asked me if I learned this in my religious upbringing as a child. My response, probably a surprise to both of us was, “No, in AA.” Suddenly, I realized just what impact AA had on the person I had become. c 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 Alcoholics Anonymous World Services. (1984). Alcoholics Anonymous. New York, NY: Author.
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Counselor | October 2018
Letter from the Editor much better information about the types of treatment available. The Subcommittee has long heard from medical experts that evidence-based treatment, including medication-assisted treatment (MAT), is the most effective method for overcoming opioid use disorder. But not all facilities provide that treatment, and some make vague promises about the effectiveness of the various treatment models they offer. Individuals seeking treatment for themselves or for loved ones often turn to the Internet to find resources to guide them in choosing a treatment center. Such online searches can prove overwhelming. Patients are often at the mercy of what they find online with little or no guidance from a medical professional. While some centers disclose their relationships with treatment facilities, others may engage in deceptive marketing tactics to hide them. Moreover, these call centers are often staffed by sales representatives rather than medical professionals. In some of the worst cases, call aggregators or call centers may refer patients to facilities that do not meet their needs based on a financial arrangement. And once patients enter treatment, they may be vulnerable to exploitation by unscrupulous business owners. Concerns raised about deceptive advertising and marketing practices have already led to action. For example, several states have passed legislation designed to prohibit unethical marketing and advertising practices; the National Association of Addiction Treatment Providers (NAATP) updated its code of ethics; and Google placed a temporary restriction of online advertising by treatment providers due to misleading experiences among rehabilitation treatment centers. The Subcommittee heard testimony from the following: n Jason Brian, founder of Redwood Recovery Solutions and TreatmentCalls.com n Michael Cartwright, chairman and CEO of American Addiction Centers
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n Mark Mishek, president and CEO of Hazelden Betty Ford Foundation n Robert Niznik, CEO of Addiction Recovery Now and Niznik Behavioral Health n Kenneth Stoller, director of Johns Hopkins Hospital Broadway Center for Addiction n Marvin Ventrell, executive director of NAATP Ventrell reported that his association—which represents 850 member facilities—has removed ninety-nine treatment campuses, operated by twenty-four parent companies, for failures to meet NAATP’s new code of ethics. This new code covers patient brokering; billing and insurance abuses; license and credential misrepresentation; and predatory and deceptive web practices. With respect to marketing ethics, NAATP’s new code describes and specifically prohibits the deceptive, misleading, and nontransparent marketing of treatment services. It is definitely a start. c
Gary Seidler
Consulting Executive Editor Counselor, The Magazine for Addiction & Behavioral Health Professionals, A Health Communications, Inc. Publication References Chopra, R. (2018). Letter to the House Energy and Commerce Committee. Retrieved from https://docs. house.gov/meetings/IF/IF02/20180724/108592/HHRG115-IF02-20180724-SD004.pdf Sanger-Katz, M. (2018). Bleak new estimates in drug epidemic: A record 72,000 overdose deaths in 2017. The New York Times. Retrieved from https://www. nytimes.com/2018/08/15/upshot/opioids-overdosedeaths-rising-fentanyl.html Editor’s Note: Readers can access the complete hearing at https://energycommerce.house.gov/ hearings/examining-advertising-and-marketingpractices-within-the-substance-use-treatmentindustry/