Coming Home To Ourselves by Nina Bingham

Our surest, steadiest place to stand is always in being true to ourselves. Yet coming home to ourselves can be such a struggle, such a journey. To be true to our calling, to our heart's desire, may simultaneously threaten our security. To stand in an insecure place takes immense courage, and difficult decisions may not look courageous to others. However, to compromise is painful in a different way; in a more profoundly devastating way that robs us of our vitality, our aliveness, our individuality. To remain true to ourselves will require a soul-searching that is revelatory and seering, and the answers we find at the end of our road may be unpopular.

Each soul has something to say. Some souls say it in an unassuming way, and some will trumpet their truth, yet a celebration is in order whenever we have heard our souls speak. We can only outrun Spirit for so long. Overnight it will outrun us, and the next day face us squarely so that it is plain to see, apparent that we've been running from what was in our own best interest all along.

While our minds are careful to remind us of the dangers of risking and reaching for our dreams, Spirit is unconcerned about any of the sensibilities of "security." Our Spirits long to live free and unhindered, unafraid, rising above conventionality and open to unlimited possibilities. The Universe is vast and expansive, a network of energy, bursting forth spontaneously with new creation and beauty. Even when nobody's looking it creates for the joy of it. Our Souls are a reflection of that creative energy, boundless and spectacular, and they remember their true natures. They haven't forgotten, even if we have. They know to live in expectancy of the miraculous. And so in this way we will always experience a tug of war, between the mind and the Spirit.  

In bowing to the Spirit, we open doors which were impossibilities to us before. An open mind is a powerful tool because that is where the magic of Spirit dwells. It doesn't live in certainty, it doesn't live in our quest for security. It lives at the threshold of an open mind. Waiting to enter, like a magical play director, to transform the barren set into a fertile valley.

So my friends, keep an open mind, even when it scares you, because the magic is found in the possibilities, which are endless when Spirit enters the scene.

When A Single Approach Isn't Enough: Treating Mental Health Issues and Substance Abuse by Nina Bingham

                                                Introduction:
 This article reviews various treatments of Addiction Disorders for co-morbid and multimorbid clients, found in a combination of Eastern and Western Psychotherapeutic applications and Psychopharmaceutical interventions. It will show that clients with both Substance Abuse Disorders and Mental Illnesses require a more comprehensive treatment plan than substance abuse clients. Etiology foundational to Substance Abuse and Mental Disorders will be discussed: trauma, stress and neuroadaptations. A synthesis of information presented in this paper concludes that use of Eastern and Western Psychotherapeutic best-practices, along with Psychopharmaceuticals, may be the best hope for treatment of co-and multimorbid clients. This paper suggests an agenda for future clinical integrative interventions for such clients. 

         Psychotherapeutic clients suffering from mental illness and addiction can benefit from a comprehensive and integrative treatment plan, combining Western and Eastern psychotherapeutic methods, including the use of psychopharmacology. The respective branches of Medicine and Psychotherapy have historically approached treating psychopathology differently. The medical model employs an arsenal of neurological agents which work to supplement neurotransmitter imbalances. Psychotherapists use cognitive and behavioral therapies to effect emotional, thought and behavioral regulation. While these two “camps,” the medical psychiatrists, and talk-therapy psychologists and psychotherapists, will often work collaboratively on the client’s behalf, there is a certain type of client which may go underserved, despite therapeutic “best practices” of both these approaches. An analysis of co-and multimorbid Substance Abuse Disordered clients reveals serious challenges facing mental healthcare practitioners: First, clients who are mentally ill are also likely to suffer from a co-morbid substance abuse disorder, and while Cognitive-Behavioral Therapy has a modest rate of success with treating addiction disorders, most therapists are not prepared by Universities to treat dual-diagnosis cases which include Substance Abuse. Second, chronically mentally-ill clients can present in counseling with multiple mental illness diagnosis, as well as many substance abuse problems. These clients are referred to herein as multimorbid individuals. Thirdly, expecting an alcohol and drug treatment program which has had success among single-diagnosis substance abuse disorder clients to be as effective for co-morbid or multimorbid clients may lead to lapse and relapse. Research shows that the current system of treating co- or multimorbidity with a single clinical approach (either medical, psychotherapeutic or addiction treatment) is shortsighted. Before exploring solutions to these complex cases of addiction, one must first consider the effects of three often-concealed addiction etiologies: trauma, stress, and neuroadaptations.

    Substance Abuse Disorders develop often in patients with mental illness, particularly in those with exposure to trauma in childhood. Therefore, mental illness and trauma are risk factors in development of substance abuse disorders. Co-morbid clients exceed 50% among younger, chronically mentally ill clients (Brown, Ridgely, Peppe, Levine, & Ryglewicz, 1989). This high percentage of younger clients would especially benefit from a multi-therapeutic, integrated-care approach. While clients use drugs to self-medicate, alcohol and drug use has been found to hinder almost every aspect of care for young adults with chronic mental illness (Brown, Ridgely, Peppe, Levine, & Ryglewicz, 1989). If the cycle of drug dependency could be resolved among co- or multimorbid young adults, both their mental and physical health would improve. Unfortunately, these clients may not view their addiction as part of the psychological problem, and may be reluctant to engage in drug treatment. Clients may prefer not to present with a Substance Abuse complaint to a clinician, and why should they? After all, it is their coping mechanism! Instead, they often present to the counselor or medical physician complaining of depression or anxiety, or another mental health condition. This is when the clinician is in a position to effect important intervention in the client’s life. “An educational format and approach is a promising way to engage reticent clients in treatment. With a psychoeducational framework, the client does not feel “singled out” (Brown, Ridgely, Peppe, Levine, & Ryglewicz, 1989). By gently yet honestly informing the client of the duality or multiplicity of his mental illness and addiction, by showing him how mental illness can understandably lead to substance abuse, the client who is building a therapeutic relationship with the counselor or physician can begin the process of accepting the truth about his condition. I believe it is the therapeutic alliance that the client has with the clinician, and the support of his family, which will enable him to accept treatment. Even among those clients with the best clinical psychoeducation and family support, the chronic dual or multimorbid client may fear the two giants looming on the horizon of his recovery: the thought of dealing with memories of trauma, and his mountain of perceived stress. What he may not realize is that in addition, his brain has been changing to accommodate and adapt to his addiction; he has developed neurology which may now support his addiction.

    As mentioned earlier, addictive behaviors are coping mechanisms. Experiments in operant conditioning proved that humans will, to their detriment, continue unhealthy and dysfunctional behaviors if there is a positive enough reinforcer. That reinforcing agent for addicted clients is the alcohol or drugs. “An operant model posits that drug abuse disorders stem from deficiencies in the environmental contingencies of reinforcement rather than from defects within the individual. That is, the individual’s environment does not contain adequate sources of positive reinforcement, and drug use, which results in immediate and powerful rewards, becomes a frequent source of reinforcements” (Bigelow, 2001). When the addict’s environment and support system is not a positive enough reinforcer, he finds his reward via the addictive payout. Further bolstering his addiction are the negative consequences of physical and psychological withdrawal he suffers when he attempts to stop: “Although positive reinforcement may play a particularly important role during initial exposures to drug effects, the role of negative reinforcement assumes increasing importance as the individual learns that the drug alleviates unpleasant affective states, including aversive states associated with drug deprivation (i.e., withdrawal)” (Bradizza & Stasiewicz, 2009). The brain becomes conditioned to expect its pleasant rewards, and to avoid cessation of the drug. Neuroadaptions occur as a result of the drugs themselves, leading to development of habitual use. What should have been self-directed goal attainment becomes habitual, compulsive substance use instead. These neuroadaptations can affect two areas of cognitive functioning: inhibitory control and decision-making (Schwabe, Dickinson, &Wolf, 2011). Common brain circuitry is involved in the development of both mental illness and addiction. As an example, chronic use of illicit drugs results in changes in the amygdala which in turn may cause chronic depression. Substance abuse disorders often occur in patients with other psychiatric illnesses, yet few such individuals receive comprehensive treatment for their dual conditions (Kuehn, 2010).

    An explanation of why substance abuse is frequently paired with mental illness is the strong association between exposure to stress during childhood or adolescence (Kuehn, 2010). Post-Traumatic Stress Disorder (PTSD) has been associated with poorer Substance Abuse Disorder (SUD) outcomes. Poorer alcohol and drug outcomes appear specific to PTSD rather than to greater psychopathy in general. “The comorbidity of PTSD and substance abuse disorders has been documented, especially in women” (Marich, 2010). Women with PTSD were found to relapse more quickly than women who did not have PTSD, and patients relapsed faster, drank more, and drank more heavily post-treatment. It has been speculated that PTSD patients fare worse than their non-PTSD counterparts because they do not receive adequate treatment for PTSD: “Only1 in 4 of the PTSD patients had received any type of psychiatric treatment. This study speculates that SUD-PTSD patients were not referred for psychiatric treatment” (Brown, Stout, & Mueller, 1999).

               In addition to trauma being correlated to SUDs, the effects of stress cannot be underestimated in the development of psychopathology and addiction. Among 2,784 clients of an outpatient program at a comprehensive addiction treatment facility, multimorbidity (a combination of multiple mental disorders combined with multiple substance use disorders), was significantly correlated with female gender, unemployment, less social support, cannabis problems, and increased treatment engagement (Costel, Rush, Urbanoski, & Toneatto, 2006). This large study shows that environmental stressors such as unemployment and low social support can contribute to multimorbidity and SUDs. “It is well known that stress is a significant risk factor for the development of drug addiction and relapse” (Schwabe, Dickinson, & Wolf, 2011). Acute stressors trigger habitual coping methods which can, without intervention, lead to relapse. Chronic stress may encourage re-emergence of the addiction, or development of a new addiction. Trauma, stress, and neuroadaptations due to addictive behaviors are at the root of the problem of addictions. How a client manages stress is at the heart of substance abuse recovery therapy. The way in which an individual processes stress can either perpetuate the addiction, or prevent a relapse. How then should a Psychotherapist proceed to effectively treat co- and multimorbid addicted clients?

    Research studies have shown that unmodified Psychoanalysis is not an effective treatment for addictions, because traditional Psychoanalysis ignored the addiction and the client’s dangerous behavior. They proceeded in this way because they were taught to treat the underlying condition first, and in so doing the addictive behavior would be “cured.” Today we know that ignoring dysfunctional behaviors is not in the client’s best interest, nor will the addictive behaviors dissolve once the root psychological problem has been treated (Yalisova,1989). While traditional Psychoanalysis ignored the substance addiction and treated the client’s underlying cognitive distortions, today’s substance abuse clinicians may be making the reverse error: treating the behavioral symptoms of addiction while not attending to the underlying psychopathology of trauma/PTSD and stress. An eclectic way of psychotherapeutic practice, where both Western and Eastern Psychotherapeutic approaches are utilized may be the best hope for treatment of co-and multimorbid clients.

    The Western medical model utilizes medication in conjunction with counseling, and consistently ranks among the most effective substance abuse treatment interventions. However, pharmacotherapy remains underutilized and presents one of the greatest implementation challenges for community-based treatment programs. Staff attitudes towards addiction medications varied significantly between treatment units (Fitzgerald, & McCarty, 2009). While some recovery programs are equipped to treat dual or multimorbid clients, others are not. A good share of clients being seen on an out-patient basis or in Psychotherapy are co- or multimorbid, and will be looking to the clinician for comprehensive answers. Several Western psychotherapeutic approaches have shown promise in treating clients suffering from comorbid trauma/PTSD and addictions: Western Eye Movement Desensitization and Reprocessing (EMDR), and Cognitive-Behavioral Therapy treating trauma (Marich, 2010).

               Traditional substance abuse programs may not have fully understood the dramatic and leading role that trauma plays in the lives of the addicted. Moreover, because the brain has adapted neurologically to the addiction, stimulation of the brain’s information processing system through Eye Movement Desensitization and Reprocessing (EMDR) can access suppressed or repressed memories, allowing the trained EMDR Therapist to navigate the painful, emotional and dreaded trauma memories to a safe and peaceful resolution. “Unfinished traumatic business” as well as symptoms of depression and anxiety can be effectively treated through this psycho-neural process (Marich, 2010). An additional Western Cognitive Behavioral Therapeutic modality that has been proven effective in complex cases of Substance Abuse Disorder is Acceptance and Commitment Therapy.

              Acceptance and Commitment Therapy (ACT) was used to study the effect that shame has on substance abuse disorders. The results showed that both Eastern Mindfulness techniques and ACT produced better attendance in treatment, as well as reduced substance use (Louma, Kohlenberg, Hayes, & Fletcher, 2012). Shame is a common experience among substance abusers; one might describe it as feelings of failure and worthlessness. These powerfully painful feelings can trigger substance use and relapse. Shame stigmatizes the individual, making them more prone to: treatment-seeking delays, treatment drop-out, and social withdrawal. Curiously, few substance abuse treatments comprehensively address the problem of shame. When Acceptance and Commitment Therapy (ACT) was applied to reduce feelings of shame, researchers Louma, Kohlenberg, Hayes, & Fletcher (2012) reported that the ACT group participants evidenced less days of substance use, had higher treatment attendance, and as shame was gradually reduced so were the substance abuse rates. While advances in Western neuropsychology have given clinicians the relatively new therapy of EMDR, and while Cognitive Behavioral Therapy and Acceptance and Commitment Therapy offers answers to the puzzle of addiction, there is another ancient therapy from the East which is finding renewed popularity and effectiveness for co- and multimorbid clients, and it comes to us from Buddhism.

    Psychotherapeutic clients suffering Addiction Disorders can benefit from Eastern Buddhist Mindfulness training; Dialectical Behavioral Therapy being one such successful therapeutic application of this training in the West. Mindfulness training, a 2,500 year old Buddhist tradition, has been shown to be effective in treating addictions (Brewer, Elwafi, & Davis, 2012). While traditional Western behavioral treatments for smoking have been mildly successful, with abstinence rates between 20% and 30%, mindfulness training has only recently been empirically “put to the test” for treatment of addictions. The results show that gradually, if the student continues to practice, mindfulness training can disrupt the addictive cycle of smoking and drug usage through the use of distraction from the drug stimulus, and concentrated focus on the here and now. By teaching individuals to more objectively observe the craving body and breathe through it, and to recognize triggers and cognitive distortions, habitual reactions to addictions eventually lose their grip and give way to a more self-determined way of life.

                At this time, due to Psychology’s relatively short history as a science, we may understand more of what doesn’t work in treatment of complex Substance Abuse Disorders than what is effective for the co-morbid or multimorbid client. Individuals who suffer from trauma, stress, and a shame-based self-concept, and who are substance users or abusers may benefit by a carefully constructed treatment plan which takes into account the history of trauma, PTSD, environmental stress and shame-based beliefs. By applying simplistic methods of substance treatment to complex cases of mental illness and substance abuse, we may be supplying a therapeutic “band-aid,” in which case the client may lapse and relapse due to the underlying psychological trauma, stress, and shame he is carrying. While modern Psychotherapy doesn’t condone ignoring addictive behavior any longer, clinicians may be overlooking the perplexing complexities of co- and multimorbidity. “Clients with multimorbidity have been neglected, and assuming that knowledge about comorbidity can be transferred to the population with multimorbidity is in error” (Costel, Rush, Urbanoski, & Toneatto, 2006).

                 This article suggests that a careful and thorough investigation of the clients past and present  be initiated through psychological assessment, and should alert the Psychotherapist to possible underlying deeper issues of dysfunctional thought and self-assessment which the client is evidencing through substance abuse. “It would come as no surprise to mental healthcare professionals that co-morbidity is common. Indeed, co-morbidity is the rule rather than the exception in clinical settings. Yet when formulating a treatment plan for people who present with co-morbid problems, it is difficult for clinicians to know where to start” (Thornton et al, 2012). In the past, existing treatment strategies have been applied unilaterally, instead of tailoring the treatment plan specifically for co-morbid clients (Kay-Lambkin, Baker, Lewin, & 2004). Co-morbid and multimorbid clients require a more comprehensive treatment plan, and could include psychopharmaceuticals, as well as a blend of Eastern and Western psychotherapeutic best-practices.

                 While Universities are doing their all to equip counselors with evidence-based methods of psychotherapeutic training for mental illness and substance abuse, there is a work to be done to unite these two schools of training within the University systems. If counselors are to practice treating the psychopathological issues in whole instead of only the presenting issue, an integration of substance abuse and mental illness curriculums should be the future foci of counselor training programs. “Clinicians and clinicians-in-training must not only acquire skills in accurate assessment and diagnosis but also be alert to the patterns of co-morbidity. At this point, clinicians have more information about the existence, patterning, and sequencing of co-morbidity than they do about effective treatment strategies. The next generation of treatment manuals for clinical trials will need to address this issue specifically” (Clarkin, & Kendall, 1992).

                To bridge the gap between research and clinical treatment of co-morbidity, the medical and psychological clinicians who are on the “front lines” of intervention of complex substance abuse disorders can strive to become more eclectic and integrative in their approaches to what remains a very difficult psychological puzzle. “Clearly,” states Berman, Jobes, & Silverman (2006), “one-size treatment does not fit all, and there is tremendous value in judiciously combining theoretical perspectives, treatments, and interventions from across the spectrum of options.” Norcross, Karpiate & Lister (2005) studied self-identified eclectic psychologists and found that, “Between one quarter and one-third of contemporary psychologists identify themselves as eclectic or integrative.” One psychologist in their study wrote, “People are different and have different diagnosis and needs as well as viewing therapy differently. Therefore, I suit the therapy to the patient.”

                In conclusion, while research has suggested an integrated treatment approach to co- and multimorbid clients, the clinical reality is structured in such a way that Substance Abuse Counselors and Psychotherapists treat complex cases of substance abuse and mental illness differently. Among Western approaches to psychotherapy, effective neurological and cognitive treatments have been proven effective, and Eastern mindfulness techniques are experiencing a resurgence of popularity in treating substance abuse and mental illness. In the future, both Substance Abuse Counselors and Psychotherapists would benefit by being equipped with a broad range of therapeutic skills, so clients can be treated in a holistic and integrative manner. As co- and multimorbid cases increase, so must our clinical response to them.

                                                                    References:

Brewer, J.A. Elwafi, H. M., Davis, J.H. (2012). Craving To Quit: Psychological models and    neurobiological mechanisms of mindfulness training as treatment for addictions. Psychology of Addictive Behaviors. Advance online publication. Doi: 10.1037/a0028490.

Marich, J. (2010). Eye movement desensitization and reprocessing in addiction continuing care: A phenomenological study of women in recovery. Psychology of Addictive Behaviors, Vol. 24, No. 3, pp. 498-507. American Psychological Association.

Yalisova, D.L. (1989). Psychoanalytic approaches to alcoholism and addiction: Treatment and research. Psychology of Addictive Behaviors, 0893164X, Vol. 3, Issue 3.

Kuehn, B.M. (2010). Integrated care key for patients with both addiction and mental illness. JAMA: Journal of the American Medical Association, Vol. 303 (19), pp. 1905-1907. US: American Medical Association.

Louma, J.B., Kohlenberg, B.S., Hayes, S.C., Fletcher, L. (2012). Slow and steady wins the race: A randomized clinical trial of acceptance and commitment therapy targeting shame in substance use disorders. Journal of Consulting and Clinical Psychology, Vol. 80 (1), pp. 43-53. US: American Psychological Association.

Schwabe, L., Dickinson, A. Wolf, O.T. (2011). Stress, habits, and drug addiction. A psychoneuroendocrinological perspective. Experimental and Clinical Psychopharmacology, Vol. 19 (1), pp. 53-63. US: American Psychological Association.

Fitzgerald, J., McCarty, D. (2009). Understanding attitudes towards use of medication in substance abuse treatment: A multilevel approach. Psychological Services, Vol. 6 (1), pp.74-84. US: Educational Publishing Foundation. Psychological Services, Vol. 6 (1), pp. 74-84. US: Educational Publishing Foundation.

Costel, S., Rush, B., Urbanoski, K., Toneatto, T. (2006). Overlap of clusters of psychiatric symptoms among clients of a comprehensive addiction treatment service. Psychology of Addictive Behaviors, Vol. 20 (1), pp. 28-35. US: American Psychological Association.

Brown, P.J., Stout, R.L., Mueller, T. (1999). Substance use disorder and posttraumatic stress disorder comorbidity: Addiction and psychiatric treatment rates. Psychology of Addictive Behaviors, Vol. 13 (2). Special Section. Substance Use Disorder and Post Traumatic Stress Disorder Comorbidity. Pp. 115-122. US: Educational Publishing Foundation. US: American Psychological Association.

Brown, V.B., Ridgely, S.M., Peppe, B., Levine, I.S., Ryglewicz, H. (1989). The dual crisis: mental illness and substance abuse: Present and future directions. American Psychologist, Vol. 44 (3), pp. 565-569.

Bradizza, C.M., Statsiewkz, P.R. (2009). Alcohol and drug use disorders. In: Behavioral mechanisms and psychopathology. Advancing the explanation of its nature, cause and treatment. Salizinger, Super; Washington, D.C., US: American Psychological Association.

Bigelow, G.E. (2001). An operant behavioral perspective on alcohol abuse and dependence. In N. Heather, T.J. Peters, & T. Stockwell, International handbook of Alcohol dependence and problems, pp. 299-315. New York: Wiley.

Clarkin, J.F., Kendall, P.C. (1992). Comorbidity and treatment planning: Summary and future directions. Journal of Consulting and Clinical Psychology., 60 (6), pp. 904-908.
Thornton, L.K., Kay-Lambkin, F., Baker, A.L., Lewin, T.J., Johnson, M.P. (2012). Reasons

           for substance use among people with psychotic disorders: Method triangulation

           approach. Psychology of Addictive Behaviors, Vol 26(2), pp. 279-288. American

           Psychological Association.
Berman, A.L., Jobes, D.A., Silverman, M.M. (2006). An integrative-eclectic approach to treatment. Adolescent suicide: Assessment and intervention (2^nd ed), pp. 207-257. Washington D.C., American Psychological Association, pp. 456.

Norcross, J.C., Karpiate, C.P., Lister, K.M. (2005). What’s an integrationist? A study of self-identified integrative and (occasionally) eclectic Psychologists. Journal of Clinical Psychology, Vol. 61 (12), pp. 1578-1594. Wiley Interscience.

How To Integrate Hypnotherapy Into Psychotherapeutic Practice by Nina Bingham

This article reviews three journal articles about how Hypnotherapy can be integrated into different psychotherapeutic situations, including: treating adult survivors of sexual abuse, post-traumatic stress, and learning disabled children. I chose to research the use of how hypnotherapy can be an asset to the mental healthcare field because I have been a practicing Clinical Hypnotherapist since 2003. I saw firsthand the successful application of this technology, and how it can compliment the way therapist of all modalities are practicing.

I was curious to see what research had to say about applying Hypnotherapeutic methods to Psychotherapeutics, because I am a Clinical Hypnotherapist and counselor, and had the good fortune of practicing in a group integrated medical practice where both Eastern and Western medicine was offered, and where I collaborated with medical and psychological physicians daily. I learned a lot from them, but they learned something from me, too. The clinical Psychologist on staff had not been trained in hypnosis and was naturally skeptical of its therapeutic value. When a patient of his inquired about my services for insomnia, since he hadn't been successful in resolving his patient's sleep problem, he asked me how I would treat insomnia. I explained that hypnosis deeply relaxes the body and mind, so that moving from the waking brainwave of Beta down to the deep sleep brainwave of Delta occurs easily and naturally. He referred his patient and I instructed him in self-hypnosis, so that when he was home he could put himself to sleep. It was such demonstrations that made a believer out of my colleagues.

However, as with any therapeutic tool, hypnosis has limited applications, and is not a magical panacea for all conditions. Since hypnosis employs Guided Imagery, or visualization as its main approach, its application is most effective and immediate for anxiety disorders, post traumatic stress, eating disorders, stress, and distorted cognition. I selected two articles that applied hypnotherapeutic techniques to adult survivors of childhood sexual abuse, and to children with developmental delays. The third article was written by Dr. Sperry who describes five techniques that psychotherapsists can incorporate into their practices with no formal hypnosis training.

In the first study, Hypnotherapy and Disabled Children (Johnson et al.,1977), three university scholars applied group hypnosis, and self-hypnosis on learning-disabled children. 15 children participated for 6 weeks of hypnotic training sessions and daily self-hypnosis, which made suggestions of improved academic performance and self-esteem. The study showed a marked improvement in self-esteem for the experimental group, but no academic improvement in reading, spelling and math. However, two additional studies suggest a relationship between self-perception and academic achievement. Jones and Stowic (1968) and Jones and Grieneecks (1970) showed that a student's self-concept of ability predicted grade-point averages more than did measures of intelligence and aptitude in both high school and college. Van Koughnett and Smith (1969) state, "For a child to achieve, he must view himself as able to achieve." How then does a clinician alter a self-perception?

One potential direction in changing self-perception is the use of suggestion to directly altar a belief system. The methodology of this approach would be hypnosis. Hypnotherapy has been used as an adjunct therapy to improve self-concept in children by suggestions of reduced anxiety, increased motivation, images of success, and increased confidence. Kroger (1963) describes its use with intellectually deficient children to increase motivation and conviction that they can learn" (Johnson, 1977).

The second report examines treatment techniques for survivors of sexual abuse. The author lists hypnotherapy and Guided Imagery techniques as suitable for them. Combined with inner-child work, adult survivors experience many negative and overwhelming emotions such as: "Anxiety, depression, self-blame, self-hatred, guilt, shame, fear, helplessness, sexual problems, memory loss, and some will suffer with suicidal ideation or attempts, self-mutilation, and unsatisfactory relationships. The child blames herself, internalizing the guilt and shame" (Pearson, 2001). Miller (1986) combined hypnotherapy with inner-child work to facilitate healing in a woman sexually abused by her father. "Often used in combination with inner-child techniques, much literature advocates using hypnotherapy and guided imagery with adult survivors of childhood sexual abuse" (Pearson, 2001). Why hypnosis in such cases? It provides a soothing, relaxing, and comfortable atmosphere for the client, a haven of safety. In the above-mentioned case, Miller (1986) "Combined hypnotherapy with inner-child work for several purposes; uncovering incest memories and associated feelings, helping the client make connections between the incest and current issues and behaviors." Norris (1986) stated, "Hypnotherapy may be the technique of choice when clients resist memories...it is an alternative technique for uncovering repressed material related to the incest." Rencken (1989) suggested that relaxation in and of itself can be therapeutic. "Relaxation can be useful for redeucing anxiety when survivors are exploring and discussing the details of abuse. Relaxation combined with Guided Imagery can improve recall of these threatening memories" (Norris, 1986).

The third article is a how-to manual for therapist who have no formal training in hypnotherapy. The first technique suggested is the Somatic Bridge, and is utilized when a client is having difficulty identifying his feelings. He is directed to turn his full attention to his bodily sensations, including mental images, memories and associations. It is a way of assisting the client to become more aware of his unspoken feelings, expressed somatically. Dr. Fritz Perls, creator of Gestalt Therapy, would ask the client, "If your tense tummy could talk right now, what would it say to you?" In this way the body serves as a bridge to the person's previously unspoken emotions.The second technique is the Emotional Bridge. The therapists directs the client to "stay with" and not resists the emotion, and see if it acts as a bridge to past memories that evoked the same feeling. The third technique is the Dissociate Technique. The therapist helps the client to see they are not the negative thoughts, actions or emotions they are experiencing, and asks them to identify and articulate the new part of herself that she is discovering. The fourth technique is Story-Telling. Milton Erickson was a famous hypnotherapist who created amazing and powerful therapeutic metaphors to tell his clients. Metaphor is an indirect method of therapy, appealing to the unconscious. The fifth and final technique is Reframing. Reframing is commonly used in both psychoanalytical and hypnotherapeutic practice. It is a way of "turning negatives into positives, assigning good intentions to participants, to change the climate, to disengage power plays, and to provide encouragement in place of discouragement" (Shermann and Dinkmeyer, 1987).

Although I can cover only a few mental disorders that respond positively to hypnotherapy, research has shown it is a therapeutic option that if used skillfully, can yield healing results. As is true with any therapeutic method, the practitioner must discern in which situations Guided Imagery and hypnosis would be helpful. It is not advisable or appropriate to treat all mental illnesses or disorders with hypnosis. Some conditions will fail to respond, yielding disappointing results. In some cases the application of hypnosis could make a bad condition even worse. Therefore, it is indicated for a psychotherapist to receive professional instruction in hypnotherapy, which includes the necessary instruction in: progressive relaxation, deepening techniques, structured suggestions or questions, post-hypnotic suggestion, and so on. If more mental healthcare professionals were trained in hypnotherapy, I believe they would regularly use this healing tool with great results, because it is a valuable additional resource to have in certain therapeutic situations.

References:

Johnson, L.S., Johnson, D, Lamont, D., Olsen, M.R., Newman, J.P. (1977). Hypnotherapy and disabled children. Journal of Clinical Psychology, 7, 12-20. Retrieved from: WWW.ebscohost.com.library.pcc.edu

Pearson, Q.M. (2001). Treatment techniques for adult female survivors of childhood sexual abuse. Journal of Counseling & Development, September/October 1995, Volume 73. Retrieved from: WWW.ebscohost.com.library.pcc.edu

Sperry, L. (1990). Incorporating hypnotherapeutic methods into ongoing psychotherapy. Individual Psychology, Vol. 46, No. 4. Retrieved from: WWW.ebscohost.com.library.pcc.edu 

Career Counseling: A Holistic Approach

Introduction: This article will emphasize a multicultural and holistic approach to Career Counseling. Included are the topics of: Career Counseling Theory, Relational Strategies when working with clients, Diversity Issues, Legal and Ethical Issues, Career Counseling Models, Assessment Tools, and the impact of crisis and emergencies on clients. My hope is this will assist counselors-in-training, or the general mental health clinician to integrate these concepts into their work with clients who are seeking career guidance.

   

    The Holistic Approach: I see career development as one class, or type of human development. After all, regardless of our gender, socio-economic status, age, educational level or culture, work gives us meaning and purpose. In some cases, work can even allow us to achieve success, and significance, or self-actualization (Maslow, 1943). So while psychological developmental theorists may not have included career development as a separate goal of human development, perhaps they should have.
    Career researchers have begun to press for a more balanced and comprehensive approach towards career counseling, one which focuses on a blend of vocational and personal counseling. "The overwhelming rationale is that career and personal issues are inseparable and intertwined" (Zunker, V.G., 2012). Applying a biopsychosocial approach to career counseling seems to be the most holistic approach. The question remains, "How to effectively integrate an individual's career and personal concerns" (Zunker, V.G., 2012).
     
    According to the history of vocational counseling, trait-and-factor theory was exclusively used. It employed the “scientific method” by utilizing psychometrics, and has been a respectable form of vocational counseling since its inception. "Super initially relied heavily on trait-and-factor theory as he counseled clients. Eventually, he loosely coalesced these perspectives into the life-span, life-space approach to careers" (Savickas, 1997). His "Career Developmental Theory" added the human developmental perspective to the vocational. By calling attention to the client's developmental stage, ecological situation, and the role of self-concept, Super established a more holistic approach to career counseling. Super defined career maturity as, "The readiness to make educational and vocational choices" (Super, 1955). He factored in such variables as: self-esteem and self-efficacy. In his own words, "The life-space, life-span model does not assume that work is the central role in a person's life; instead, it highlights the importance of the work role in relation to other roles" (Super, 1984). 

     
    The Case of Naomi: In the case of Naomi, a single, biracial mother of three young children who is employed but looking for another job, one of my first questions in assessing her overall ability to make a career transition would be to inquire how much support she has in caring for three children. If she has no support, it might be difficult for Naomi to even attend career counseling appointments. She states her mother and sister watch her children on occasion. With this in mind, I would want to understand Naomi's reasons for her current job dissatisfaction. She states she is making over 30K annually and has been with the company long-term. Although she complains she is "living paycheck to paycheck," for a person with only a GED and low-to-average intelligence, this doesn't seem to be an untoward situation. Therefore, I would do some preliminary investigating with Naomi to discover: is she experiencing alienation at work? Are there problems with peers or supervisors? Does she feel overloaded or stressed? Is she “burned out” and bored with her work? Before launching into job-search mode, I would be very careful to ask searching questions to uncover the true problems with her current position. With some inter-personal communications coaching, Naomi may be able to improve her current position at work. If Naomi has solid reasons for making a job change and it seems modification of her current position is not an option, then I would blend two Career Counseling models: the Happenstance Approach Theory (Mitchell, Levin, and Krumboltz, 1999) and CIP. First I will explain application of the Happenstance Approach.
   
    The Happenstance Model: I choose this theory because Naomi is a woman, biracial, and a single mother of three who is obese and has diabetes. These factors could cause Naomi to feel there is not much hope for her to get ahead in life. The Happenstance Approach "Suggests that counselors are to help clients respond to conditions and events in a positive manner" (Zunker, 2012, p. 36). This model stresses development of the following qualities: Curiosity, persistence, flexibility, optimism, and risk-taking. Of the practical steps involved in this model, the following seem most important for Naomi:
1. Use of interest inventories to establish her capabilities and interests.
2. Skills Training.

3. Addressing procrastination or uncertainty about decision-making.
4. Addressing personal barriers to attaining goals. For example in Naomi's case, she may need to find suitable childcare if she is to return to school or be occupationally re-trained for a different line of work.
5. Job clubs for vocational social support should be offered as a resource.
6. Cognitive Restructuring-Discussing negative statements about self and the future with the client.
7. Behavioral Counseling Techniques-Role playing with the client, or desensitization to aversive stimulus.
    In Naomi's case, conveying my belief in her can deepen her own sense of self-efficacy. To be her "collaborator" means I should remind Naomi that although she is faced with challenging life circumstances, she has also succeeded in the work world in the past, and has the inner resources to move to her next level of potentiality.

     
    Diversity and Disability in the Workplace: Naomi is biracial, which means she is a client of diversity, a client of color. She is also a woman, which is a sexual minority. Though she is not disabled, her lower education level and her diabetes are factors in finding a “right fit” for Naomi in the workplace. Given these factors: diversity, legal and ethical issues should be integrated into the counseling approach with Naomi. "To meet minimum standards of practice, therefore, counselors will be required to become proficient in disability issues" (Hayes, 2001; Hulnick & Hulnick, 1989). Today’s counselors are working with a many-cultured client base. "As populations change from homogenous groups to a mosaic of people with diverse cultures and customs, career counselors must shift their perspectives from monoculturalism to multiculturalism" (Hartung, 2002; Leong & Hartung, 2000).
    
     Historically in rehabilitation counseling there have been prominent models (Smart & Smart, 2006) that counselors have used when working with the disabled:
1. Biomedical Model-Still the most prevalent perspective today. This model defines disability with the language of medicine. This model assumes pathology is present. "Objectification" of the client can open the door for treating the client in a dehumanized way. This model views the disability as a defect, abnormality and medical problem. Because of this view, it can stigmatize the client.
2. Environmental Model-Poverty, lack of education, ethnic identification, gender, sexual orientation, and age are some sociological factors which define this model. “Partial responsibility for the response to the disability rests upon "society" to provide a physically accessible and non-prejudiced environment" (Smart, & Smart, 2006).
3. Sociopolitical Model-Also referred to as the "Minority Model of Disability" (Hahn, 1997; Kleinfield, 1979) is the most recent model. In this model, the disabled refuse to accept the inferior, dependent, and stigmatizing definition of a disability. If society has constructed these artificially limiting constructs, they can culturally de-construct them. This model refuses to allow society to define disability as being: handicapped, inferior, or the object of discrimination or prejudice. "Many scholars and researchers state that the prejudice and discrimination directed towards people with disabilities have been more pervasive than any other group of people, and further, much of this has been due to the Biomedical Model" (Smart & Smart, 2006).
   
     To best serve the disabled or minority client, counselors should take the following steps (Smart & Smart, 2006): 
1. Counselors should discuss the client’s feelings and experiences about the disability or minority status.
2. Counselors should know that most disabled clients do not embrace the Biomedical model, and prefer to view their disability as a valued part of themselves, and see the "positive aspects." Clients prefer not to believe in focusing solely on their limitations.
3. Counselors should realize the disability is but a part of the client's existence; it does not determine it.
4. Counselors should seek to empower the client: "As professionals, our goal is to promote our client's full participation and integration into their communities" (Tate, 2001, p. 133).
5. Counselors should not impose their values on the client. Counselors should refrain from coaching the client to, "Try harder,” or its opposite, tell the client they are in "denial" of their disability, these clients may terminate counseling prematurely because they have felt misjudged.
6. Be mindful of the power differential between client and counselor. Be sensitive and aware that it increases when the client is disabled.

     
    Ethical Considerations When Working With Clients: In regards to ethical consideration for Naomi, the National Career Development Association (NCDA) Code of Ethics (2007) distinguishes two types of counseling: career planning vs. career counseling (A.1.b.). Because Naomi has environmental factors such as her single parent status and her health problem, it would benefit Naomi if her counselor took a holistic approach to counseling her, such as described in the NCDA's description of "career counseling."
An understandable and accomplish-able Service Plan should be developed with Naomi's assistance, to guide her career exploration, especially since she has borderline intelligence and only a GED (A.1.d.). Since Naomi is a single parent but has family and a church for support, the counselor should, with Naomi's permission, enlist the assistance of any support network that could assist her in professional upward mobility (A.1.e.). Cultural sensitivity should be shown since Naomi is biracial (A.2.c.). In Naomi's case this may mean the counselor should not assume which culture Naomi feels most "part of," but to allow Naomi to disclose her feelings on her community and ethnicity. In addition, gender is an important factor in career counseling, because there are some professions that are typically "male," and can be resistant to females. I do not, however, subscribe to the idea that females should tailor their career choices to the opinions of that career's norming group. Example: If a woman wants to be a construction worker, and she has the initiative to learn the trade's necessary skills, there is no reason she cannot become a construction worker. I would not only review "traditionally" female-held professional roles with Naomi, but offer those which she may not have considered before due to her gender.

      
     Cognitive Information Processing Model: In addition to the Happenstance Approach outlined above, another favorite model is the Cognitive Information Processing (CIP) Model (Peterson, Sampson, and Reardon, 1991) due to its Individualized Learning Plan (ILP), and attention to client metacognition. This 7-step process includes the following activities: (1) Interview (2) Assessment (3) Defining Problems/Analyzing Causes (4) Formulate goals-Individualized Learning Plan (5) Develop ILP-Steps to accomplish ILP (6) Execution of ILP (7) Summative Review-Determine Effectiveness (Zunker, 2012, p. 103).  

    I would apply the CIP Model in the following ways with Naomi: (1) Interview-Establish rapport and clarify Naomi’s career problems. (2) Assessment-Because Naomi has borderline intelligence, administer the Career Thoughts Inventory (Sampson et al., 1996a) to measure her ability to problem-solve and make decisions (3) Define Problems/Analyze Causes-Counselor/Client agreement on existential career problem (4) Individualized Learning Plan (ILP)-Naomi’s goals are developed and put in writing (5) Develop ILP-Prioritize goals and activities to achieve goals (6) Execute ILP-Counselor assists Naomi in identifying and overcoming sources of anxiety and challenges in implementing ILP, including analyzing metacognition and defeating self-talk (7) Summative Review-Review all steps of the CIP Model with Naomi, so she can apply them in the future. The Cognitive Processing Model asks the counselor to check the client’s metacogntions for any limiting, negative self-assessments or beliefs, and it allows the counselor to unearth any mental health or substance abuse issues. In fulfilling this dual-role of vocational coach and counselor, a true collaboration takes place, and a stronger relationship is formed. When we see the client multi-contextually, as the Cognitive Model suggests, we view the whole person, and not just a part. We come to understand a multi-faceted person, one whose life involves her career aspirations, but which is also influenced by her finances, family, education and culture. When we see “the whole picture,” the client may too.

  
     Career Search Systems and Assessments:  In regards to career search systems and resources, the O*Net Online is helpful in outlining vocational trends. I also find the Dictionary of Occupational Titles (4th Rev. Ed.), (Department of Immigration, 1991) aids in defining occupational titles and responsibilities. Standardized tests and self-assessments can psychometrically evaluate the client’s career beliefs, identify skills, proficiencies and abilities, identify academic achievement, confirm interest levels, and determine values (Zunker, 201, p. 149). In addition, computerized state and city career search systems can research the local labor markets.

    
    Clients In Crisis: It is important to mention that clients like Naomi may present while in a state of crisis or because of an emergency. For example, let’s say that Naomi was laid off without any notice due to downsizing. As the sole bread-winner for her three children, this may constitute a financial emergency for her. Naomi is suddenly a displaced worker, and fears she may not be able to re-enter production work due to the physical limitations that her weight and diabetes have caused her. She is looking for direction, and possibly to make a change in careers. My plan of action with Naomi would be to:
1. Assess the severity of her physical problems. I would refer her to a physician for a physical. Based on the results of that examination, we would know her limitations and capabilities.
2. After identification of her employment history and skills, discussion of her values, and writing of an autobiographical sketch (Zunker, 2012, p. 289), Naomi can decide on the type of career she would like, and research the qualifications for those positions.

4. Individualized Learning Plan-A detailed plan of action to achieve her new career goals is the final step in assisting Naomi to respond positively to the career emergency she finds herself in. Naomi's challenge is going to be implementing a self-directed academic and/or career plan without changing course mid-stream because of her financial worries. She will be challenged to "stay with her life plan.” For her, being self-directed and avoiding becoming discouraged will be a necessary achievement for her continued career growth and development.

  
    How The Client Benefited: Naomi benefited from a combination of the above-described Career Models in the following ways:

(a)  She explored and clarified her current job dissatisfaction.

(b)   She utilized Interest Inventories and Psychometric Assessments to uncover her capabilities and interests

(c)    She enlisted the support of her existing social support system

(d)   She addressed procrastination, uncertainty, and problems in decision-making

(e)    She addressed any personal issues that might be barriers to attaining her goals

(f)    She addressed negative thinking patterns about herself and her future

(g)   She participated in Skills Training, and role-playing with the Counselor. This might include: Skills of building an effective resume, appointment setting for the interview, the interview process, overcoming objections that the employer might have, and how to follow-up with an employer

(h)   Lastly, the client scheduled a followed up appointment with the Counselor to report her progress, and to ask any questions she might have.

   
Conclusion: Modern Career Counselors have a multitude of functions to perform, most important of which is to assess the client to understand her holistically; how both her personal and professional life impacts her career-making decisions. The Counselor must be multiculturally trained and apply methods which have been empirically proven to meet the specific cultural needs of the client. In utilizing a Career Counseling model, the Counselor works to improve the client’s self-awareness, identifications of skills, and prioritization of action steps.

    Assessment tools can be used to psychometrically assess and test the client’s abilities and areas for improvement. In the event of a client crisis or emergency, the Career Counselor plays the role of triage “nurse,” referring the client to community resources she might need immediately, while also providing career and psychological intervention. Career Counselors have an arsenal of techniques and assessments with which to meet the following demands: “Work problems, stress reduction, mental health concerns, and develop programs that enhance work skills, interpersonal relationships, adaptability, flexibility, and other interventions that lead to self-efficacy” (Zunker, 2012, p. 7). These counseling activities are associated with career choice over the life span. Truly, a Career Counselor’s work is never done.

    References

Maslow, A.H. (1943). "A Theory of Human Motivation," Psychological Review 50(4): 370-96.

Zunker, V.G. (2012). Career Counseling: A Holistic Approach. Eighth Edition. BROOKS/COLE CENGAGE Learning.

Savickas, M.L. (1997). Career Adaptability: An Integrative Construct for Life-Span, Life-Space Theory. The Career Development Quarterly, March 1997, Vol. 45, pp. 247-259.

Super, D. E. (1949). Appraising vocational fitness by means of psychological tests. New York: Harper & Row.

Super, D. E. (1953). A theory of vocational development. American Psychologist, 8, 185-190.

Peterson, G.W., Sampson, J.P., Reardon, R.C., and Lenz, J.G. (1996). A cognitive information processing approach to career problem solving and decision making. Career Choice and Development, (3rd edition, pp. 423-467), San Francisco: Jossey-Boss.

Sampson et al. (1996a). Career Thoughts Inventory: Professional manual. Odessa, FL: Psychological Assessment Resources.

Mitchell, K.E., Levin, A.S., and Krumboltz, J.D. (1999). Planned happenstance: Constructing unexpected career opportunities. Journal of Counseling and Development, 75, pp. 155-124.

Zunker, V. G. (2012). Career Counseling: A Holistic Approach. Eighth Edition. BROOKS/COLE CENGAGE Learning.

Capella University. (2012). Americans with Disabilities Act Video. Retrieved from: http://breeze.capellauniversity.edu/p87439021

United States Justice Department. (1990). AMERICANS WITH DISABILITIES ACT OF 1990, AS AMENDED. Retrieved from: http://www.ada.go/pubs/adastatute08.htm#12101b

American Governing Counsel. (2005). ACA Code of Ethics. American Counseling Association, Alexandria, VA.

National Career Development Association Ethics Committee. (2007). Code of Ethics. National Career Development Association, Broken Arrow, OK.

Smart, J.F., Smart, D.W. (2006). Models of Disability: Implications for the counseling profession. Journal of Counseling and Development: JCD 84.1, 29-40.
Hayes, P. A. (2001). Addressing cultural complexities in practice: A framework for clinicians and counselors. Washington, DC: American Psychological Association.

Hulnick, M. R., & Hulnick, H. R. (1989). Life's challenges: Curse or opportunity? Counseling families of persons with disabilities. Journal of Counseling & Development, 68, 166-170.

Tate, D. G. (2001). Hospital to community: Changes in practice and outcomes. Rehabilitation Psychology, 46, 125-138.

Chan, F., Hedl, J., Parker, H., Lam, C., Chan, T. N., & Yu, B. (1988). Differential
attitudes of Chinese students toward people with disabilities: A cross cultural
perspective. The International Journal of Social Psychiatry, 34, 267–273.

Paris, M. J. (1993). Attitudes of medical students and health-care professionals
toward people with disabilities. Archives of Physical Medicine and Rehabilitation,
74, 818–825.

Westbrook, M. T., Legge, V., & Pennay, M. (1993). Attitudes towards disabilities
in a multicultural society. Social Science Medicine, 36, 615–623.

Lewis, R.A., Gilhousen, M.R. (1981). Personnel & Guidance Journal, Vol. 59 (5), pp. 296-299.

Peterson, G. W., Sampson, J. P., Jr., & Reardon, R. C. (1991). Career development and services:

A cognitive approach. Pacific Grove, CA: Brooks/Cole.

Zunker, V.G. (2012). Career Counseling: A Holistic Approach. Eighth Edition. BROOKS/COLE CENGAGE Learning.

Sampson, J.P., Jr., Peterson, G.W., Lenz, J.G., Reardon, R.C., Saunders, D.E. (1996a). Career thoughts inventory: Professional manual. Odessa, FL. Psychological Assessment.

Dryden, W. (1979). Rational-emotive behavioral therapy and its contributions to careers. British Journal of Guidance & Counseling, 7, p. 181-187.

Williamson, E.G., Biggs, D.A. (1979). Trait and factor theory and individual differences. In H.M. Burks, Jr., & B. Stefflre (Eds.), Theories of counseling. New York: McGraw-Hill, 1979.

Keller, K.E., Biggs, D.A., Gysbers, N.C. (1982). Career Counseling from a Cognitive Perspective. Personnel & Guidance Journal, Vol 60(6), pp. 367-371.

Peterson, G.W., Sampson, J.P., Reardon, R.C. (1991). Career development and services: A cognitive approach. Pacific Grove, CA: BROOKS/COLE.

DeVito, J.A. (2009). The Interpersonal Communication Book. Twelfth Edition. Pearson.

US Department of Immigration. (1991). Dictionary of Occupational Titles (4th Rev. Ed.), Retrieved at: http://www.occupationalinfo.org/

Lowman, R.L. (1993). Counseling and psychotherapy of work dysfunctions. Washington D.C: American Psychological Association.