TraumaOnline
The newsletter of the
International Trauma Training Institute (ITTI)
Mike Dubi, Ed.D., LMHC, Editor
Jeanne Thomas, MBA, Associate Editor
 
November 2019, Vol. 2, No. 6
Greetings and Happy Holidays:

After conducting a 2-day workshop on trauma in Boise, I was able to take a few days off to explore the Sawtooth Range. What a truly beautiful country the USA is!
In this issue of TraumaOnline, we are pleased and excited to announce another new course: Substance Use Disorders (SUD), 13 NBCC CE Hours, created and taught by Jim Reynolds, Ed.D., LMHC, MAC. Jim has more than 35 years experience as an addictions clinician and teacher and presents an interesting and important course.

SUD is in the 6-module, 6-week format and in addition to the Fundamentals, participants will learn about Classification of Drugs (including Opioids), Treatment Interventions and Modalities, Addiction and the Family, and Relapse Prevention. This SUD course, along with our Neurobiology of Addiction , and Treatment of Sexual Addiction courses, represents the continuance of ITTI's addictions track.

Our core course: Clinical Trauma Professional continues to be our most popular offering, telling us that the need for trauma education for mental health professionals is one of the most crucial tools in a therapist's tool box.
We are also planning additional courses in the Treatment of Anxiety, Disaster Mental Health, Advanced Hypnotherapy, Expressive Arts, Yoga, Play Therapy, Family Systems, and Therapy with the Elderly.

Have you checked out our journal yet? The Practitioner Scholar is loaded with relevant articles to help you in your critical work with traumatized clients. We also welcome submissions by experts who are seeking to publish in a professional journal. Please send your abstract to the editor: joffreysuprina@verizon.net

Best regards,
Mike Dubi, Ed.D., LMHC
President
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ARTICLE

Working with Substance Use Disorder Clients and Therapist
Self-Awareness
by
Jim Reynolds, Ed.D., LMHC, MAC

“The other night I ate at a real nice family restaurant. Every table had an argument going” (George Carlin)

During my experience teaching graduate substance abuse and addiction counseling courses over the past several decades, I became aware of an interesting phenomenon. At first it struck me as strange that some students adamantly expressed strong feelings that they did not want to work with substance use disorder (SUD) clients. Another group of students had selected this specialty area as the population or presenting problem that they most wanted to work with. The client population of SUD clients was almost like a dividing force and I was interested in trying to understand this divide. 

Exploring this observation further, I became aware that a students’ previous experience with their own substance abuse, or exposure to other addicted individuals in their lives appeared to be a significant contributor to their personal position regarding working with this population. It was relatively easy to understand the strong motivation of some students who had dealt with SUD themselves, and were in recovery and expressed a dedication to help other addicted individuals. Many from this group of students expressed a strong desire to share (for the benefit of their clients) what they had experienced and learned in their own addiction and recovery process. However, the other group of students who were aversive to working with SUD individuals were a bit more difficult to understand.

As I reflected upon my own life and career choices, I experienced a deeper understanding of both groups of students regarding their positive or negative inclinations to work with SUD individuals. For myself, having grown up in an alcoholic household, it was fairly clear how my career choices and motivations for working in the SUD field were influenced. My father died of alcoholism when I was in graduate school, and I had experienced many if not most of the classic signs and symptoms of a child of an alcoholic family when I was growing up. At various stages of adulthood, I have sought, and believe I have benefited from personal psychotherapy regarding this family issue. It is no accident that my choice of career has been in the SUD field. During my doctoral program I worked on a grant having to do with alcoholism. The title of my doctoral dissertation was “Treatment and Personal Correlates in Relapse of Alcoholics”. My very first job out of graduate school was as an alcoholism counselor in a hospital 28-day treatment program. I was a clinician in the addiction field for over 25 years, working in all kinds of settings, including hospitals, inpatient and outpatient programs, long-term and short-term programs, various kinds of addiction counseling agencies, and private practice specializing in addictions counseling. I was a Certified Addictions Professional (CAP) in Florida for many years and served for 8 years as a board member and chair of the written test committee and am currently a Master Addiction Counselor (MAC) through the National Association for Alcoholism and Drug Abuse Counselors (NAADAC). In sum, to state the obvious, my career choices have obviously been affected and influenced by my own family experiences. 

Focusing upon the group of students who have expressed to me an aversion to working with the SUD population, I would like to share some thoughts. First, we are all products of our histories. Consequently, if a psychotherapist has had adverse personal experiences with addicted individuals in their past, they may have strong negative emotions when SUD clients remind them of their past experiences. In psychodynamic theory, the term “countertransference” is often invoked to refer to personal reactions of the therapist to circumstances of the client that the therapist is reacting to (often unconsciously). Many individuals in the general public, including professional therapists, have had negative experiences with family members, friends, co-workers, etc. regarding the behaviors of individuals who are addicted. However, the American Counseling Association (ACA) Code of Ethics addresses the issues of imposing values, and respect for client’s well-being. Therapists need to be very clear about imposing their own values, and having respect for their clients.

Many if not most SUD clients experience intense shame, guilt, and remorse. It is important that the therapist has “unconditional positive regard” for their clients. Research has established the importance of the “the therapeutic alliance” and it’s influence upon treatment outcome. The attitudes and beliefs of the therapist are critical to the therapeutic alliance. If therapists believe that addicted clients are “hopeless”, or other myths such as treatment isn’t effective or doesn’t work, or that it’s all a matter of “will-power”, and that relapse is inevitable, these myths will likely negatively affect the client and treatment outcome.

What can we do to help reduce the negative impact that the foregoing might have upon SUD clients? First and foremost, education regarding SUD is imperative. Therapists need to know and understand the dynamics and effects of substance abuse upon their clients, including neurological, biological, psychological, social, cultural, and even spiritual impacts for these individuals. It’s not surprising that many state licensing boards require a course in substance abuse counseling in order to obtain licensure as a clinical mental health counselor.

In addition to education, therapists need to be aware of their own attitudes and biases regarding addictions. Many counselor educators stress the importance of self-awareness and many experienced clinical supervisors believe that self-awareness is perhaps the most important quality for a therapist to develop. Irving Yalom stated that “your greatest instrument is you, yourself, and the work of self-understanding is endless.” Yalom also states that “Self-awareness is a supreme gift, a treasure as precious as life. This is what makes us human.”

So how do therapists develop and become more self-aware? One way of enhancing self-awareness is through personal therapy. Many, if not most counselor educators advocate for personal psychotherapy for their students. In fact, some counselor education programs require that students have personal psychotherapy. It is believed that therapists need to be aware of their own personal issues and are working on these issues so that they are not unintentionally or unconsciously imposed upon clients. Again, Yalom states that “Therapists need to have a long experience in personal therapy to see what it’s like to be on the other side of the couch and see what they find helpful or not helpful”.

In sum, treatment of substance use disorders is not attractive to all therapists. Some therapists clearly have a negative reaction to this presenting problem. It is important for therapists to be aware of their attitudes, feelings, beliefs, and reactions to this population. Therapists would be advised to maintain their personal self-awareness in this regard, and to utilize supervision and personal therapy in order to ethically provide effective treatment for this population. Individuals with Substance Use Disorder can provoke many different reactions from all of us, including those of us who are clinically working with this population. Therefore, we need to be continuously aware of our own personal histories and maintain ongoing awareness of our personal reactions to this presenting problem.

"Until you make the unconscious conscious it will direct your life, and you will call it fate" (C.G. Jung)
About the Author

Jim Reynolds completed his doctorate in Counselor Education and is licensed in Clinical Mental Health Counseling (LMHC) in Florida. He is certified as a Master Addiction Counselor (MAC) through the National Association of Alcoholism and Drug Abuse Counselors (NAADAC).

Jim is also an Approved Clinical Supervisor by the National Board for Certified Counselors (NBCC).

ARTICLE

The Basics About Demoralization Syndrome
by
Tamara Fass, LMSW

The mention of the psychological disorder “demoralization syndrome” is rarely met with a knowing, “Yes, of course!” Unfortunately, this reality extends to human service professionals. More commonly, physicians and mental health professionals respond to the term demoralization syndrome with passivity and indifference. Demoralization syndrome is defined as the loss of a sense of purpose and confidence in the future, an erosion of the essence of psychological wellbeing. This essence is not a factor in the diagnostic constructs of other psychological disorders. The experience of demoralization is clinically meaningful, yet demoralization syndrome has been relegated to obscurity. That is, until now. Scientific literature has recently revealed two astounding findings which have made demoralization syndrome impossible to ignore.

The first and most critical finding is that demoralization syndrome has been in hiding in plain sight, masquerading as depression. Demoralization syndrome is misdiagnosed as depression at an alarmingly high rate, with associated dire consequences. The second finding is that demoralization is a strong predictor for suicide, even more than depression. Therefore, mental health professionals have a duty to educate themselves about the new data surrounding demoralization syndrome, despite its complexity. Fortunately, valid and reliable information can be found off the beaten path, in academic literature. With that, all excuses have officially expired, and it is time for professionals to up their game.

Research Evolution

The best way to learn about demoralization is by following the evolution of the research. The journey was started in the 1960’s by Jerome D. Frank, a psychiatrist and professor at Johns Hopkins University School of Medicine. He conducted research on hundreds of patients to study methods of psychotherapy. In his book, Persuasion and Healing, Frank asserts that successful psychotherapy targets demoralization and restores a sense of mastery. Subsequent researchers recognized the importance of continuing Frank’s work. With curiosity as their guide researchers took over where Frank left off and dedicated themselves to further studying demoralization. All that has been uncovered about demoralization and demoralization syndrome is attributed to their efforts.

The primary goal of early research was to firmly establish the difference between demoralization and depression. Many of the symptoms of demoralization syndrome overlap with symptoms of depression. However, unlike demoralization, depression presents with anhedonia, which means lack of present enjoyment. In contrast, demoralization allows for pleasure in the present. When a patient experienced symptom of depression but without anhedonia, the patient still received a diagnosis of depressive disorder, with the modifier “not otherwise specified.” Early researchers learned that the correct diagnosis was instead: demoralization syndrome.

Demoralization syndrome was newly defined as a combination of two psychological constructs: “existential distress” and “subjective incompetence.” Existential distress and subjective incompetence make demoralization syndrome a crisis of spirit, where distress is not present based but rooted in the future. It is marked by anticipatory distress experienced as helplessness and hopelessness. Known as the hallmark of demoralization syndrome, existential distress is based on an anticipated loss of dignity in situations where there is a threat to life or basic human dignity. Feelings of hopelessness develop as the meaning of past experiences is destroyed; tried and true coping mechanisms prove ineffective. When this threat is an inevitability, a helplessness sets in where one’s sense of self-efficacy, self-esteem, and self-worth are at stake. Demoralization syndrome takes hold as the inability to control outcomes is viewed as a personal failing, not an unfortunate reality of a given circumstance. Nothing short of an attack on Self, this harsh self-blame provides the script for subjective incompetence. The self-imposed belief of incompetence is an assault on meaning, purpose, and most of all hope.

Research in Patient with Cancer

Terminally ill patients suffering with cancer were the most widely studied population in demoralization syndrome research. Researchers were drawn to study terminally ill cancer patients based on the confusion of clinicians as their “depressed” patients were not responding to typical depression-based psychotherapy and psychotropic medications. The reason for this unexpected response can be understood by considering the role of motivation. Motivation fuels hope as potentially effective options present themselves. Demoralization can be understood as a feeling of “ stuckness ,” meaning, while motivation may be in ample supply confidence in deciding upon a course of action no longer exists. When previously effective coping strategies repeatedly prove ineffective profound disappointment and despair sets in. Depression is experienced by a feeling of constant and consistent feeling of depletion, drained of motivation. At the same time, depression does not compromise the ability to identify which course of action would be most effective in a given situation. The message of depression-based psychotherapy is, “Try harder! You can do it!” For demoralized patients, that message, in fact, could not be more useless. Cheerleading exacerbates helplessness and hopeless, where eventually patients develop complete burnout, where even mundane tasks of daily living become too much. This is what full-blown demoralization syndrome looks like.
End of Life

The need for research for demoralization specific therapy became urgent as clinicians observed that patients receiving depression-based interventions were developing a sudden and intense interest in pursuing end of life hastening options. The central threat of this reaction was the ability for this intense wish to create physician countertransference. Researchers found that that palliative and hospice settings were breeding grounds for physician countertransference. The physician of a patient with untreated demoralization syndrome risked losing their objectivity because they aligned with the patient’s loss of meaning and purpose and wished for hastening death. From both an ethical and moral standpoint, the patient’s right to self-determination is a priority. It is therefore critical to ensure patients feel empowered and dignified.

Dignity Therapy

One of the most important tasks of end-of-life care providers is ensuring that patients develop and maintain a sense of dignity. Dignity Therapy was developed for precisely this reason. Dignity Therapy is a brief, individualized psychotherapy for patients receiving hospice or palliative care and is the gold standard treatment modality for demoralization syndrome. Dignity therapy restores dignity, heals the crisis of spirit, existential distress, and subjective incompetence. It is important to note that dignity therapy protocol does not include any measured on increasing motivation.

Dignity Therapy is comprised of personal interview with patients, where they discuss their important memories, accomplishments, and lessons learned in life. In addition, they discuss hopes or dreams for their loved ones. This interview is recorded, and the dialogue is used to create a narrative. In the subsequent sessions the patient and clinician work together to on creating a “legacy document” based on the initial interview. This document becomes tangible evidence for the patient on the value of the past, the purpose of the present, and a meaningful contribution for the future. In one fell swoop, dignity therapy restores morale. Satisfaction rates for dignity therapy are astoundingly high. In a study on 100 patients, 91% reported feeling satisfied or highly satisfied with the intervention. Eighty six percent reported that the intervention was “helpful” or “very helpful.” Seventy six percent indicated that it heightened their sense of dignity, and 68% indicated that dignity therapy increased their “sense of purpose.” Sixty seven percent reported a heightened “sense of meaning,” and 47% of participants reported an increased “will to live.”

The Future of Demoralization Research

The effects of demoralization are incredibly far reaching. research shows that demoralization syndrome is not limited to physical illness but has the same predictive validity in cases of psychological trauma, with a direct correlation to prolong PTSD. The next stage of research lies in developing standardized assessment tools and treatments. Researchers, unfortunately, have hit a roadblock. Much of the current literature reflects the reality that advancements will rely on demoralization syndrome becoming an official diagnosis. Without an official diagnosis, obtaining funding for research and development of assessment tools and treatment is made exponentially more difficult. To correctly diagnose demoralization syndrome, researchers needed to create new tools for diagnosis. Depression assessment tools were not designed to measure anything other than presence of depression. For all intents and purposes, the future of demoralization syndrome in the hands of American Psychiatric Association (APA), through inclusion in the Diagnostic and Statistical Manual of Mental Disorders (DSM). The passionate plea for an official diagnosis leaps off the pages of the literature preceding the release of the DSM-5 . Many were hoping that one of the changes from DSM-4 to DSM-5 would be the addition of demoralization syndrome. The central argument for an official diagnosis is to create a common language for information sharing. With a diagnosis, demoralization syndrome will be recognized by all human service disciplines. Alas, demoralization syndrome did not make the cut for the DSM-5. Literature following the publication of the DSM V is filled with disappointment and frustration over the omittance. Fortunately, researchers remain dedicated to their quest despite this setback.

Stay Curious

The best way to actively support further research is to join researchers in to follow their lead and stay curious. Does that advice to “stay curious” come across as dismissive? Perhaps to some. But not to Albert Einstein. Einstein said: “Curiosity is more important than knowledge.” Richard Schwartz, developer of Internal Family Systems Therapy (IFS), is a staunch advocate of curiosity. As is well known, IFS has become a staple of trauma therapy, and has impacted the lives of countless individuals. In a recent interview , [1]  Richard Schwartz was asked what advice he would offer new clinicians. “Stay curious” he said. The word curious, in fact, was used eight times throughout the interview. Curiosity is the spark of discovery and advancement. The risks in a passive “never heard of that” response, can easily be mitigated through a curious, “what is that?” Answering that question is not difficult. With access to a plethora of sources with valid and reliable information, professionals can easily access the wealth of evidence-based data on demoralization syndrome. Until demoralization syndrome is embedded into the fabric of professional standards, promoting awareness is not only a responsibility but an obligation. It will be the passions of the curious that will protect demoralization syndrome from fading into oblivion.
Stay curious!
References

Ballenger, J. C., Davidson, J. R. T., Lecrubier, Y., Nutt, D. J., Marshall, R. D., Nemeroff, C. B., Yehuda, R. (2004). Consensus statement update on posttraumatic stress disorder from the international consensus group on depression and anxiety.  The Journal of Clinical Psychiatry, 65 (suppl 1.), 55–62. Retrieved from https://pdfs.semanticscholar.org/c02c/35051d33506cd016f597249cd0492faeb2ac.pdf
Bovin, M. J., Marx, B. P., & Schnurr, P. P. (2015). Evolving DSM diagnostic criteria for PTSD: relevance for assessment and treatment. Current Treatment Options in Psychiatry , 2 (1), 86–98. doi: 10.1007/s40501-015-0032-y
Connor, M. J., & Walton, J. A. (2011). Demoralization and remoralization: a review of these constructs in the healthcare literature.  Nursing Inquiry ,  18 (1), 2–11. doi: 10.1111/j.1440-1800.2010.00501.x
Donato, S. C. T., Matuoka, J. Y., Yamashita, C. C., & Salvetti, M. D. G. (2016). Effects of dignity therapy on terminally ill patients: a systematic review. Revista Da Escola De Enfermagem Da USP , 50 (6), 1014–1024. doi: 10.1590/s0080-623420160000700019
Figueiredo, J. M. D., & Frank, J. D. (1982). Subjective incompetence, the clinical hallmark of demoralization. Comprehensive Psychiatry , 23 (4), 353–363. doi: 10.1016/0010-440x(82)90085-2
Grassi, L., & Nanni, M. G. (2016). Demoralization syndrome: New insights in psychosocial cancer care. Cancer , 122 (14), 2130–2133. doi: 10.1002/cncr.30022
Kissane, D. W., Clarke, D. M., & Street, A. F. (2001). Demoralization syndrome — a relevant psychiatric diagnosis for palliative care. Journal of Palliative Care , 17 (1), 12–21. doi: 10.1177/082585970101700103
Kissane, D. W. (2014). Demoralization: A life-preserving diagnosis to make for the severely medically ll. Journal of Palliative Care , 30 (4), 255–258. doi: 10.1177/082585971403000402
Kohn, R. (2013). Demoralization and the longitudinal course of PTSD following Hurricane Mitch. The European Journal of Psychiatry , 27 (1), 18–26. doi: 10.4321/s0213-61632013000100003
Macpherson, G. (2015). Episode 163- Richard Schwartz PhD. The Trauma Therapist Podcast. Retrieved from https://www.thetraumatherapistproject.com/podcast/richard-schwartz-phd/
Sansone, R. A., & Sansone, L. A. (2010). Demoralization in patients with medical illness. Psychiatry (Edgmont (Pa. Township)) , 7 (8), 42–45.
Vehling, S., Kissane, D. W., Lo, C., Glaesmer, H., Hartung, T. J., Rodin, G., & Mehnert, A. (2017). The association of demoralization with mental disorders and suicidal ideation in patients with cancer. Cancer , 123 (17), 3394–3401. doi: 10.1002/cncr.30749
About the Author

Tamara Fass, LMSW, is a licensed social worker in the state of New York specializing in the field of trauma with a focus on trauma-informed care. As a consultant, she guides organizations in implementing trauma-informed practices. Tamara assists with program development, assessments, training, evaluations, and grant writing. As a creative thinker and avid researcher, She initiates and participates in collaborative research projects and is currently developing a parenting workshop on raising resilient children. Tamara can be reached via email at  TamaraFass@gmail.com

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