Counseling

In response to my post, GASP!, a friend sent me some links to articles about acupuncture. Specifically, acupuncture was compared with counseling and treatment as usual for depression.

What is "counseling"? I've heard the word used any number of times, and I think I just assumed that it's what people say when they don't want to say "therapy", because they think "therapy" sounds too stigmatizing. Or it's therapy as practiced by someone not specifically trained in therapy,  per se, like the clergy.

But maybe not. Is it therapy? A specific kind of therapy? How does it differ from therapy, if at all? Who practices it, and why are they called counselors rather than therapists? Why would someone want counseling rather than therapy?

I Googled "What is counseling", and I got some interesting links.

There's the American Counseling Association, which offered this definition:

Professional counseling is a professional relationship that empowers diverse individuals, families, and groups to accomplish mental health, wellness, education, and career goals. 

They provide further detail:

Counseling is a collaborative effort between the counselor and client. Professional counselors help clients identify goals and potential solutions to problems which cause emotional turmoil; seek to improve communication and coping skills; strengthen self-esteem; and promote behavior change and optimal mental health.

Okay, so counseling is some kind of professional relationship involving mental health.

According to the site, there are 4 different types of counseling: Individual, Couples, Family, and Group. There's a little blurb about each of these, and interestingly, the Family blurb, but none of the others,  uses the word, "therapy".

There are a number of counseling specialties, including but not limited to:

Career and employment
School
College
Marriage
Military
Wellness
Adult Development and Aging/Gerontology
LGBTQ issues
Substance

and something called, "Assessment". When I clicked that link, it explained:

Counselors, educators, and other professionals advances the counseling profession by promoting best practices in assessment, research, and evaluation in counseling. Assessments are a systematic way to obtain information about the client’s problems, concerns, strengths, resources and needs.

Does this mean some counselors specialize in taking a history? I can't tell.

There are state licensure requirements. There are also 2 certifying boards, although certification is not required.

The National Board for Certified Counselors requires passing an exam, the National counselor Examination (NCE).

It also requires:

-Master’s degree in counseling or with a major study in counseling from a regionally accredited institution
-3,000 hours of counseling experience and 100 hours of supervision both over a two year post-master’s time period
-Post-master’s experience and supervision requirements are waived for graduate students who have completed CACREP accredited tracks.

I don't know what those tracks are.

The Commission on Rehabilitation Counselor Certification (CRCC) is the other board. It has its own exam, and a number of ways of meeting eligibility criteria for certification, which seem to involve supervision, work experience, a Master's or Doctoral level degree in Counseling or Rehab Counseling, or an advanced degree in one of 13 areas:

Behavioral Health                         Psychology
Behavioral Science                       Psychometrics
Disability Studies                          Rehabilitation Administration/Services
Human Relations                          Social Work
Human Services                           Special Education
Marriage and Family Therapy         Vocational Assessment/Evaluation
Occupational Therapy


I still don't understand the difference between counseling and therapy. I found a site with a piece called, "Psychologist v. Counselor". It claims that:
-Counselors usually have a master's level degree, and generally don't do research, or perform psychometric testing, though some get further training to so they can.
-Some psychologists get licensed as counselors.
-And:

Psychologists are more likely to work with individuals with serious mental illness. They are trained to perform psychotherapy with a range of clients, but in many settings, general therapy roles will go primarily to counselors and other master’s level mental health practitioners. The reason? These individuals are more cost effective.

Bottom line: I still don't know what counseling is. It seems like "counselors" have a certain type of training, +/- certification, with varying backgrounds and degrees. But what they do remains a mystery to me, although it sounds like therapy.

Gene Kelly At The Waldorf

This is the main lobby at The Waldorf. The clock is taller than it seems in the photo. That's probably why I never noticed the little lady liberty at the top.

I want to write about one of the discussion groups I attended, the Service Members and Veterans Initiative that I mentioned in my previous post, Waldorf 2015. As preparation, I watched "Combat Fatigue Irritability",  a short film directed by and starring Gene Kelly, which was made for the Navy, to make people aware of symptoms of PTSD. The film was only referenced, not shown, during the group discussion, but it was interesting to hear from his daughter, Kerry Kelly Novick, who led the group. I kept wanting to ask her the completely irrelevant question of, "What is it like to see your father on the big screen?"

She did mention that her father was quite steadfast in his insistence on an accurate portrayal of the main character, Seaman Lucas', symptoms and behavior. He even had himself admitted to a psychiatric hospital to prepare for his role.

In the film, Lucas had worked on a ship that was blown up. His job was to monitor the pressure valves. He never went topside as part of his work. He never knew what was going on. He was not a gunner, so he had no active outlet. All he did was monitor the valves, and feel increasingly frightened and helpless. When his ship was destroyed, and he found himself in the water, he felt relieved, but also horrified at watching his buddies die around him.
After he is rescued and recovered, he has a 30 day furlough, and he returns home. At first things go well with his family, but he feels increasingly isolated and not understood, has trouble reuniting with his girlfriend, startles and gets angry when her little brother throws a paper airplane at him, gets into a fight with a bartender, and starts to shake uncontrollably when he goes hunting with his father, after which, he is hospitalized.
The film shows his coming to terms with some of his feelings in group therapy. The psychiatrist is portrayed as kind but somewhat patronizing and paternalistic, and places an emphasis on "fear that wasn't handled properly" as the origin of Lucas' symptoms. He is also shown sedating him, immediately following Lucas' breakthrough in understanding.

There were a number of interesting points made by various people, most of whom work with soldiers or veterans regularly. One idea that I hadn't considered is that the characters portrayed in the film, like most men in the military during World War II, were just regular guys who were drafted. Whereas today, we have an all-volunteer military, so those who have chosen to serve have done so with the intention of making it their career. They want to remain in the service, which makes them that much more reluctant to acknowledge when they are having emotional difficulties.

There was discussion about Lucas acting as "bad" as he felt he was, for his wish to escape from the boiler room, and then watching his comrades die. And of guilt as a defense against helplessness. Someone noted Freud's comment about the soldier's conflict between the wish to live and the wish to be a good soldier.

Isolation was another topic that came up in the discussion group, as illustrated by the sense Lucas has of not being understood by anyone who hadn't had similar experiences. The idea was that it's important for the clinician and for family members to recognize that this is so, but that those suffering from PTSD symptoms can use this isolation to defend against acknowledging feelings of guilt at their reactions to traumatic events, and feelings of loss-that to truly return to their former lives, they need to recognize that they have lost the versions of themselves that existed before the trauma.

One analyst has been working on petitioning the AMA to include military history as part of the social history for the E/M CPT code. Her group wanted the wording to be, "Have you or a loved one been in the military?" So far, they've gotten "you", but no "loved one".

An unfunded (by the military) area that someone brought up was pets. He said that the military has put together some research to show that pets are not that helpful in recovery for veterans, despite having evidence to the contrary. Basically, the military just doesn't want to pay for it. I don't think I came across this document when I wrote, The Comfort of Dogs.

The question of funding is an interesting one, especially in light of the opinion piece published in the NY Times a couple days later, After PTSD, More Trauma, written by a veteran, David Morris, who sought therapy for PTSD, and was placed in Prolonged Exposure Therapy, heavily promoted by the VA for its effectiveness. In this type of treatment, the patient repeatedly reviews his traumatic experience, over the course of a number of sessions. This turned out to be a bad choice of therapy for him, and he got worse, until he dropped out. He later underwent the VA's other PTSD therapy, Cognitive Processing Therapy, which he found helpful.

Morris notes the VA's contention that 85% of PTSD patients are helped by Prolonged Exposure Therapy. He cites a 2013 JAMA Psychiatry paper, Effectiveness of National Implementation of Prolonged Exposure Therapy in Veterans Affairs Care, that demonstrates evidence supporting the use of this treatment. It's open source, so you can read the whole thing, if you like. As usual, I'm skeptical about research that involves nothing but before and after checklists to establish efficacy, and a treatment for which the clinicians received 4 days of training, and then provided 8-15 sessions of therapy including, "(1) imaginal exposure or systematic and repeated exposure to the traumatic memory; (2) in vivo exposure or systematic and repeated engagement with nondangerous activities and situations that have been avoided because of trauma-related distress; (3) psychoeducation about treatment and common reactions to trauma; and (4) breathing retraining," to treat something so complicated.

Morris then goes on to state:

After my experience with prolonged exposure, I did some research and found that some red flags had been raised about it. In 1991, for example, Roger K. Pitman, a professor of psychiatry at Harvard Medical School, conducted a study of exposure therapy on Vietnam veterans and observed some troubling complications: One subject developed suicidal thoughts, and others became severely depressed or suffered panic attacks. A similar study, published in the Journal of Traumatic Stress in 1992, found that Israeli army veterans experienced an increase in the “extent and severity of their psychiatric symptomology.”

My concern is that the military has strong motivation for funding the most cost-effective, and not necessarily the most effective, treatments. No doubt it feels compelled to conserve its financial resources for use in war-related technological advances that will create more soldiers with PTSD.

It's also interesting to think about the contrast between what the military thought was useful treatment for PTSD back in 1945, and what it thinks now.

It was quite moving to hear people speak about their work with soldiers and veterans. Here's a link to the Service Members and Veterans Initiative page, if you want to learn more about the program.