Tag Archives: mental health

Post-Partum (now Peripartum) Depression: What you should know . . . and some resources to help you know it

Note: This post is provided for individuals interested in learning more about post-partum or peripartum depression. It’s also a supplement for the recent Practically Perfect Parenting Podcast on “Post-Partum Depression.” You can listen to the podcast on iTunes: https://itunes.apple.com/us/podcast/practically-perfect-parenting/id1170841304?mt=2

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For the first time ever on planet Earth, the latest version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) includes the diagnosis of Peripartum Depression. Although I’m not usually a fan of labeling or big psychiatry, this is generally good news.

So, why is Peripartum Depression good news?

The truth is that many pregnant women and new moms experience depressive symptoms related to pregnancy and childbirth. These symptoms are beyond the normal and transient “baby blues.” Depressive symptoms can be anywhere from mild to severe and, combined with the rigors of pregnancy, childbirth, and parenting a newborn, these symptoms become very difficult to shake.

But the most important point is that Peripartum Depression is a problem that has been flying under the RADAR for a very long time.

Approximately 20% of pregnant women struggle with depressive symptoms. The official 12-15% estimates of post-partum (after birth) depression in women are thought to be an underestimate. What makes these numbers even worse is the fact that society views childbirth as a dramatically positive life event. This makes it all-the-more difficult for most pregnant women and new moms to speak openly about their emotional pain and misery. And, as you probably know, when people feel they shouldn’t talk about their emotional pain, it makes getting the help they deserve and recovering from depression even more difficult.

Jane Honikman, a post-partum depression survivor and founder of Postpartum Support International has three universal messages for all couples and families. She says:

  • You’re not alone
  • It’s not your fault
  • You will be well

Keep in mind that although peripartum depression is thought to have strong biological roots, the first-line treatment of choice is psychotherapy. This is because many new moms are reluctant to take antidepressant medications, but also because psychotherapy is effective in directly addressing the social and contextual factors, as well as the physiological symptoms. Additionally, as Ms. Honikman emphasizes, support groups for post-partum depression can be transformative.

Below, I’m including links and resources related to peripartum or post-partum depression.

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A very helpful informational post by Dr. Nicola Gray: http://cognitive-psychiatry.com/peripartum-depression/

Books by Jane Honikman can be found at this Amazon link. Her books include: I’m Listening: A Guide to Supporting Postpartum Families.  https://www.amazon.com/s/ref=dp_byline_sr_book_1?ie=UTF8&text=Jane+I.+Honikman&search-alias=books&field-author=Jane+I.+Honikman&sort=relevancerank

Although it’s true that peripartum depression can be debilitating, it’s also true that it can be a source of personal growth. Dr. Walker Karraa shares optimistic stories of post-partum related trauma and growth in her book:

https://www.amazon.com/Walker-Karraa/e/B00QTWH9PW/ref=dp_byline_cont_book_1

 

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A Relationally-Oriented Evidence-Based Practice Model for Mental Health Counselors

This paper is an adapted summary and extension of an article recently published in the Journal of Mental Health Counseling (April, 2015, pp. 95-108). The original article was titled: Evidence-Based Relationship Practice: Enhancing Counselor Competence. This abbreviation and adaptation is primarily designed to summarize the content, but also to focus more directly on the implications of developing an evidence-based model especially for mental health counselors. This paper ends with an “Appendix” outlining specific parameters of an evidence-based mental health counseling model. The Appendix material isn’t in the original article. If you’re a member of the American Mental Health Counseling Association, you can find the original article here: https://amhca.site-ym.com/?JMHCv37n2

Foundations

There are two domains that serve as a foundation for all competent mental health practice. These are:

1. Ethical practice
2. Multicultural sensitivity.

Professional counselors must practice ethically. At minimum, this means abiding by the ACA (2014) and American Mental Health Counselors Association (AMHCA; 2010) ethical codes. Ponton and Duba (2009) referred to this commitment as a covenant professional counselors have with and for their clients.

Traditional theoretical perspectives must be modified or expanded to address cultural diversity (J. Sommers-Flanagan, Hays, Gallardo, Poyralzi, Sue, & Sommers-Flanagan, 2009). Clients should not be expected to adapt to their counselor’s theory; rather, counselors should adapt their theory or approach to fit clients (Gallardo, 2013). Although multicultural competence is an ethical mandate, the need to embrace multicultural awareness, knowledge, and skills is also a practical reality. [The original article lists six evidence-based ways in which mental health counselors can adapt their counseling services to be more multiculturally sensitive.]

Evidence-Based Counselor Competence

Given the nature of professional counseling and counselor identity, it seems obvious that mental health counselors should embrace a model for counseling competence and EBP that emphasizes therapeutic relationships. That is why the model I propose considers both theoretically and empirically supported relationship factors and specific interventions (procedures). . . .

The reality is that relational acts and treatment methods are so closely interwoven that in counseling sometimes it is difficult to discern which is operating at a given moment (Lambert & Ogles, 2014). Consequently, the following Relationship-Oriented Evidence-Based Practice (ROEBP) behavioral descriptions incorporate both relational and technical components. The ROEBP behavior list primarily focuses on evidence-based relationship factors, although these relational factors are nearly always teamed with technical procedures.

Evidence-Based Relationship Factors

Each mental health counselor will inevitably display therapeutic relational factors in unique ways that may be difficult for other practitioners to replicate, because anything relational or interpersonal is alive, automatically unique, and therefore resists sterile descriptive language. Nevertheless, counselors can implement the following core relational attitudes and behaviors in their own unique manner and still adhere to EBP principles.

Congruence and Genuineness

In mental health counseling, the counselor is the instrument through which treatment is provided. This is probably why Rogers’s original core condition of congruence (1957) is still central to counseling efficacy. However, because Natalie Rogers (Sommers-Flanagan, 2007) once told me that she believed very few mental health professionals in the U.S. really understand her father’s work, let me make four brief points about congruence [You can read the original article to get the details on this].

The Working Alliance

In 1979, Bordin described the working alliance as a three-dimensional and pan-theoretical therapeutic factor. The three dimensions were (a) forming an emotional bond; (b) counselor-client goal-consensus or agreement; and (c) task collaboration. Researchers have affirmed that these working alliance dimensions contribute to positive treatment outcomes (Horvath, Re, Flückiger, and Symonds, 2011). [Practical ways in which mental health counselors can apply these three dimensions in their work are described in the article.]

Unconditional Positive Regard or Radical Acceptance

Originally, Rogers (1957) described unconditional positive regard as the counselor “experiencing a warm acceptance of each aspect of the client’s experience” (p. 98). This is, of course, often impossible. Though unconditional positive regard is easy and natural when counselor and client values are aligned, the competent counselor recognizes that there will be many discrepancies, small or large, between what the counselor thinks is right and what the client thinks is right. I recall a Pakistani Muslim supervisee who reported that hearing people talk about being gay or lesbian made her feel physically nauseated. To her credit, she worked through this (over a period of two years) and was able to embrace an accepting attitude. . . .

In addition to Rogers’s work, I’ve found Marsha Linehan’s dialectical behavior therapy concept of radical acceptance (1993) very helpful. As someone who has logged many counseling hours with clients who display challenging behaviors, remembering radical acceptance helps me greet even the most extreme and disagreeable (to me) client statements with a genuine accepting response (usually something like, “Thanks so much for sharing that with me and being so honest about what you think”).

Empathic Understanding

You should already be thoroughly familiar with Rogers’s ideas about empathy and the robust empirical support for empathy as a contributor to positive counseling outcomes. However, one important caveat about empathy is that the personal feelings of counselors and ratings of their own empathy are relatively unimportant. What matters is whether and how much clients experience their counselors as empathic. This is a crucial distinction. It is all too easy for all humans—including counselors—to focus on their side of interpersonal experiences. When it comes to whether empathy is a facilitative therapy condition, it is the client’s judgment of whether the counselor was empathic that predicts positive outcomes. . . .

Rupture and Repair

Getting it wrong is a natural part of life and counseling. There will always be empathic misses, poorly timed disclosures, and intermittent disengagement. These should be viewed as inevitable problems in the working alliance. As in many other areas of life, tension in the counselor-client relationship offers both danger and opportunity.

The danger is that counselors will ignore, overlook, or be unaware of relationship tensions or ruptures, in which case clients will be more likely to drop out of counseling and outcomes will be adversely affected. But the chance to correct our missteps is an unparalleled therapeutic opportunity. It involves the powerful process of self-correction and refocusing on the client and the counselor-client relationship. . . .

Although there are many ways to repair or work through relationship rupture, the original article discusses two overarching approaches.

Managing Countertransference

Thirty years ago Steve de Shazer (1984) not only reported that “resistance” had died as a therapeutic concept, he held a funeral for it in his backyard. Similarly, some counselors and psychotherapists might like to bury the whole idea of countertransference, putting it out of sight and out of mind. However, renaming or ignoring constructs will not make them go away.

Counselors are more effective when they are aware of and deal with their own unresolved emotional and behavioral reactions (Hayes, Gelso, & Hummel, 2011). Personal counseling or psychotherapy, clinical supervision, participation in peer supervision groups—such practices can help counselors become aware of and gracefully work through their countertransference reactions.

Implementing In- and Out-of-Session Procedures

Proponents of ESTs and EBP emphasize the importance of employing specific psychological or behavioral procedures with clients. Among the procedures that have empirical support are relaxation, exposure, behavioral activation, and problem-solving (Sommers-Flanagan & Sommers-Flanagan, 2012). In addition, some procedures, such as eye movement desensitization reprocessing (EMDR), have significant empirical support even though it is not clear whether the eye movements themselves or other parts of the tightly controlled EMDR protocol are the “active” ingredients. To be consistent with an evidence-based mental health counseling model, professional counselors should implement empirically supported procedures, but should do so using a collaborative interpersonal process. . . .

Progress Monitoring

Progress monitoring (PM) is a relatively new phenomenon on the evidence-based scene. PM is robustly related to positive outcomes and relatively easy to apply (Meier, 2015). Although not covered by many professional counseling publications, all practicing counselors should integrate some form of PM into their practice.

PM simply means that, formally or informally, counselors consistently check with clients about “how things are going.” Data from empirical studies consistently show, however, that practitioners who use formal progress monitoring rating scales tend to have both more favorable outcomes and fewer negative outcomes or treatment failures (Meier, , 2015). . . .

Concluding Comments

Mental health counselors can and should integrate evidence-based approaches into their practice. Although it might be useful for counselors to seek training in ESTs, embracing and applying evidence-based relationships as a core component of counselor competency is more consistent with professional counselor identity. The purpose of making this distinction and providing the information in this article is to advocate for an alternative evidence-based identity—one that counselors can more wholeheartedly embrace.

In this article I focused on nine relational factors that are empirically linked to positive counseling outcomes. This is only a beginning. Research will continue, and for space reasons I neglected several dimensions of counselor-client relational interactions that are consistent with professional counselor identity. For example, other than a brief discussion of PM, I did not address the potential merits and problems of formal assessment. In the future I would hope for a more distinct assessment model that specifies how counselors interact with clients, emphasizing transparency and collaboration. But that discussion must wait for another day. Until then, I wish you all the best as you incorporate relationally-oriented evidence-based counseling principles into the exceptionally important services you provide.

References are included in the original article

Appendix

[This is added material]

A General Practice Model for Evidence-Based Mental Health Counseling

Different professional groups use different terminology for describing their usual and customary standards for clinical practice. In psychology “empirically-supported” is often, but not always used as a means for identifying an approach that meets scientifically-based standards. Physicians and psychiatrists establish “practice parameters” for treating specific disorders. For example, the American Academy of Child and Adolescent Psychiatry (AACAP) has a Committee on Quality Issues that has generated practice parameters for depressive disorders, obsessive-compulsive disorders, multicultural competency, and many other areas of child and adolescent psychiatric clinical practice.

Given that psychology and medicine have their own language for referring to evidence-based standards, it might be useful for professional counseling to come up with its own terminology. This would be terminology that reflects an emphasis on achieving wellness (rather than the medical model) as well as the relational emphasis consistent with counseling. In the Journal of Mental Health Counseling article I referred to this as: Relationship-Oriented Evidence-Based Practice (ROEBP). This isn’t bad, but I’m guessing someone might be able to do better at capturing counselor identity within an evidence-based practice.

Here’s a first try at outlining an ROEBP for mental health counseling. I recognize that this is mostly a rough outline, but also believe that any practice guidelines that are established for professional mental health counselors should be broad so as to include many different and unique styles that exist among individual counselors.

1. All mental health counselors embrace their professional ethical guidelines and use multicultural sensitivity and appropriate multicultural adaptations when working with individual clients. These foundational competencies and commitments must be present for a professional counselor to claim he or she is practicing evidence-based mental health counseling.

2. Mental health counseling is initiated using a collaborative informed consent process. This process should include both written informed consent (consistent with HIPAA), but also verbal interactions to help make every specific counselors approach and style explicit to prospective clients.

3. When referral information is available to mental health counselors, at least some of this information is shared directly with clients using a positive and strength-based format and interaction.

4. Mental health counselors intentionally employ empirically-supported relationship factors throughout counseling. These include, but may not be limited to:

a. Having an office-setting and interpersonal demeanor that contributes to the development of a positive emotional bond between client and counselor

b. Developing a list of mutually agreed upon problems or goals that constitute the main focus of counseling. This involves a collaborative and empathic process.

c. Working with clients on in-session tasks or procedures that are explicitly linked to the mutually agreed upon counseling problems or goals.

d. Congruence and Genuineness

e. Unconditional Positive Regard or Radical Acceptance

f. Empathic Understanding

g. Managing Ruptures and Engaging in Repair

h. Managing Countertransference

5. Recognizing that clients are sometimes drawn toward and benefit from the application of specific therapeutic procedures, mental health counselors seek permission to use these procedures with clients if they are appropriate for the remediation of a particular problem and/or for client personal growth. The procedures employed should be empirically supported. If they are not empirically-supported (e.g., procedures from energy psychology) clients should be informed that the procedure may be promising, but is not a standard and accepted counseling procedure.

6. Mental health counselors use either a formal or informal progress monitoring procedure to consistently check with clients regarding the client’s perception of counseling progress.

Feel free to email me at john.sf@mso.umt.edu with comments about this article summary and ideas about evidence-based mental health counseling practice.

When Giving Gives Back

For several years Rita has been having first year counseling students do at least five hours of “volunteer” work with our local day treatment center for clients (or consumers) who struggle with chronic mental disorders. This year Rita is on sabbatical and so the task fell to me. To be honest, I was ambivalent about the assignment, mostly because the logistics seemed challenging. I had to arrange two separate organizational visits to the mental health center for about 15 students with different schedules before the volunteering could start and I struggled to make these happen in a timely manner. I secretly wondered if arranging this experience would be worth the hassle.

On Monday, October 29, I finally met the first group at the Day Treatment program and was emotionally transported back to the early 1980s when I was worked in a Day Treatment program and then as a recreation therapist at a 23-bed private psychiatric hospital. I listened as a staff member gave us the most unstructured orientation ever. He eventually told us that he was a “client” at the center before becoming staff. He told the students they were free to just drop in and hang out whenever. I could feel the students’ anxiety rising at the thought of just hanging out and so I asked a few questions and told a couple stories to take up time and they asked questions of their own. In an odd mix of awkwardness and genuineness and anxiety, I felt the wish to just hang out with the day treatment clients myself.   

But instead of hanging out, the reality of other responsibilities started pressing forward and I left with unresolved emotions. I decided to deal with those emotions by writing a small check to support the River House Day Treatment Member Fund. I wrote the check and sent it off.

After completing their five volunteer hours, our students are required to write a short essay about their experience. Today, I’ve spent much of my day reading these essays. They are amazingly open and appreciative of the experience. Some samples:

“I am always humbled by the willingness of others to not only be open with me and to share with me their experiences but also by the ‘sameness’ of a lot of human experiences and suffering.”

“It felt good to share in the humanness of it all- bad days, favorite things, boyfriends, girlfriends, family, and trying to find meaning even when our stories are so different.”

“The clients were not only positive and loving toward the staff members, but also towards me as a volunteer. Every client I was able to talk to complimented something about me and they were constantly complimenting each other.”

“The clients I talked with accepted me in to their community and openly shared their experiences with me. This allowed me to see the world, in a small way, through their eyes.”

Every essay has emphasized the positive environment, the loving-kindness of staff and patients, and the surprise and joy of making deeply human connections. I also received an excellent formal thank-you note from the program director (for the small donation). In it she enclosed a short note from the clients or members of the Day Treatment Center. They wrote:

Thank you so much for the monetary gift. We appreciate it so much. Your students have blessed us with their presence and we have enjoyed them. I hope that we can give the students a fresh perspective on how a special place such as River House can do good and help its members. I hope you will always feel welcome here and thank you for all you do, mentoring the students and giving gifts to us.

This letter and the feelings I get when I read “Your students have blessed us with their presence . . .” was much bigger than what I gave. That’s the same message I keep getting from my students. They went with minimal expectations, a little angst, and to clock their required hours. But instead of just completing a simple assignment, they received an experience so meaningful that many of them have are extending their volunteer work far beyond the required five hours.

This is a fabulous example of how giving can give back much more than what was originally given. This is probably what Adler meant by Gemeinschaftsguful.

Thank-you to the River House staff and members for . . . BLESSING US with YOUR presence.