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.

PE-No, I Don't Mean Physical Exercise! Solving Premature Ejaculation in Men by Nina Bingham

In the case of "Bob & Jane," Bob has presented with Premature Ejaculation (PE), and admits is has been a chronic problem for him. "Premature ejaculation (PE) is widely believed to be the most common male sexual problem, averaging between 20% and 30% prevalence" (Althof, 2007). It has impacted his long-term relationships negatively, and Bob states he is ready to solve the problem. Bob was recently laid-off from his job, and has become increasingly anxious that his girlfriend of 4 months may leave him. This anxiety has been converted into sexual performance anxiety. Both Bob and his girlfriend are eager to resolve the problem.

What Causes PE: He was referred by his medical physician, who ruled out any biological etiology. However, Waldinger et al., (1998) found that 91% of men with lifelong PE had a first relative with lifelong PE. This is convincing evidence that genetics may be involved in lifelong PE. Also, there is other evidence that PE is related to decreased central serotonin neurotransmitions (Waldinger et al., 1998).

Emotional issues are another reason that a male can experience PE: "Anger, frustration, low self-confidence, mistrust, negative body image, and psychosocial stress associated with financial difficulties, occupational problems, and the death of a significant other may be factors (Metz, McCarthy, 2003; Metz, & Pryor, 2000). Chronic psychological disorders such as: bipolar disorder, depression, and generalized anxiety disorder can produce PE. Even temporary psychological difficulties like adjustment disorders can result in the disorder as well" (Metz, & McCarthy, 2003). Lastly, sexologists also attribute PE to problematic relationships (Betchen, 2001; Metz, & McCarthy, 2003).

Treatments Options: In treating this medically: "Anti-depressant medications are often prescribed for premature ejaculation" (McCarthy, Fucito, 2005). This is because Seratonin (a neurotransmitter in the brain) is the primary neurotransmitter which regulates ejaculation. In treating this Psychotherapeutically:
Sexologists attribute PE to problematic-couple relationships. Lack of communication about sex, power and control struggles, (Betchen, 2001, 2006), and haste in intercourse due to shame-based beliefs about sex (Betchen, a991; Kaplan, 1974; Metz, & McCarthy, 2003).

If the couple's relationship seems to be conflictual, "Both partners are urged to attend the first session (counseling). This allows the clinician to evaluate each partner as an individual and in the context of the interaction" (Betchen, 2006). Berman (1982) recommends seeing both partners together increases the chance that the couple will see their problem as systematic rather than the sole responsibility of one partner.
This is a couple who are still relatively new to one another, who are having no other conflicts in the relationship, and the girlfriend is supportive in hopes of finding an answer. According to the DSM-IV-TR, this would be ED which is Lifelong, vs. Acquired. Lifelong disorders can be more challenging to treat, because they have become a conditioned pattern over years. It also seems to be a Generalized Type vs. Specific Type (meaning that the pattern has occurred with all partners), and seems to be due to psychological factors (vs. organic cause).

Treatment Plan: My treatment plan would be to emphasize to Bob that a Lifelong Disorder can be overcome, but it will mean he must be willing to experiment, and try some different approaches and methods. "If the PE is found to be solely organic in origin and is treated successfully with medication, treatment will obviously be brief. In most cases, however, the PE symptom will not dissipate until psychodynamic conflicts have improved—this often takes longer" (Betchen, 2009). I would tell Bob that PE has been successfully treated by use of anti-depressants (SSRI). I would ask if his physician discussed this with him? I would ask Bob to question his physician about the use of anti-depressant for PE if the physician did not review this medical option with him. If Bob wishes to address the issue non-medically, that can be effective, too.

I would next psychoeducate the couple on the 4 stages of sexuality: Desire, Arousal or Excitement, Orgasm and Resolution (DSM-IV-TR, p. 536), and explain it is the Arousal or Excitement Phase wherein Bob needs to build skills, before he reaches the Orgasm phase.

I would ask them each to discuss the problem from their perspective in counseling, including their feelings, how it has impacted them, and their guesses as to why it is happening. This would give me a better understanding as to the inter-personal dynamics, and any underlying conflicts for the couple.

I would explain PE Exercises, and review each of them in detail, and answer any questions that the couple has about execution of the exercises. I would assign them exercises to get started practicing, and ask them to keep a brief journal on the progress and any set-backs they experience or questions they have.

Lastly, I would encourage them to return for a "follow-up" appointment to review how effective the  exercises were for them, and to answer further questions or concerns they might have. Within a few visits, this couple's problem could be a thing of the past.

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Betchen, S.J. (2009). Premature Ejaculation: An Integrative, Intersystems Approach for Couples. Journal of Family Psychotherapy, 20:241–260. Copyright © Taylor & Francis Group, LLC.