Tag Archives: unemployment

Alternative Counselor Roles


The role of the “advocate” is one I believe counselors are naturally aligned to, and should consider.  One example where I currently serve as an advocate is vocational training for intellectually challenged adults.  The reality is that most of us, on or about the age of 16, were able to get a hiring manager to “take a shot in the dark” and hire us with no experience.  The unfortunately truth is that isn’t the case for the developmentally disabled or the intellectually challenged population, thereby necessitating the need for “transition placement” and subsequent advocacy on the behalf of that population.

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Understandably, the business establishment has good reason to be weary of something it does not fully understand… I think that is part of human nature and cannot be faulted to a certain degree.  Every hiring manager should have the reassurance that someone is capable of fulfilling their duties as an employee, and it’s not entirely unreasonable to ask the question of someone who is intellectually challenged (after all, they would ask it of a “normal” applicant).  Vocational training gives people with developmental disabilities the opportunity to prove themselves, and the opportunity to demonstrate that they “have valuable skills” and can make a “lasting contribution to a business.”

For example, I currently work with an individual who only 8 years ago was “pigeon-holed” by the developmental model.  It was assumed that this particular individual would never grow “beyond the capacity of a child” and, as a result, he was largely treated as a child.  Through a rigorous process of cognitive, social and skills training… he has become “one of the most productive people on the line” at a local business.  I recently spoke with his employer, and he “regrets even hesitating to pick him up, as he now considers him among the most competent employees he has.”   Granted, the work is pretty basic, but this particular individual is fiercely loyal, driven to succeed, and competent at most basic assembly tasks.  That kind of independence would not have been possible without our advocacy.

Despite the fact that I am not yet a full time paid therapist, I can play the advocate role today.  Even now, I have clients who are consistently told by family and friends that “they will never be able to do that.”  I endeavor to break as many of those molds as is possible, as I believe in the general premise put forth by Dr. Marc Gold:  “The behaviors our children show are a reflection of our incompetence, not theirs.”  With regard to the training I would need to fulfill that role, I believe it is already underway.  I would be better able to advocate for an individual as a therapist, because I could bring the weight of a DSM-IV diagnosis to bear, and speak with knowledge about “what’s typical” and “what’s realistic” for a specific individual.  I believe the role as an advocate, especially for people whom are intellectually challenged, is key role we as counselors can play in their development of cognitive, social, skills based functioning.

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Comorbidity: Substance Abuse Disorders (SUDs)


Comorbid, or comorbidity, is literally defined as “recurring together.”  (Shiel, Jr. & Stoppler, 2008, p. 94)  For our purposes, comorbidity will refer to cases where two or more psychiatric conditions coexist, and where one of the conditions is a substance abuse disorder (SUD).  “There are 11 groups of substances specifically discussed in the DSM-IV: alcohol; amphetamines and related sympathomimetics; caffeine; cannabis; cocaine; hallucinogens; inhalants; nicotine; opiates; phencyclidine and related drugs (PCP); and sedatives, hypnotics, and anxiolytics.”  (Colman, 2009, p. 741)  Any one of the above substances, or combination of the above substances, can contribute to and be related this discussion of comorbidity with SUDs.

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Although this list is by no means exhaustive, “long-term substance use is related to psychiatric conditions such as suicide and depression, affective disorders, eating disorders (ED), and personality disorders (PD).”  (Netherton, Holmes, & Walker, 1999, p. 248)  Increased risk of mood disorders has been documented across all substance categories and across all mood related diagnoses.  (Blaney & Millon, 2009, p. 287)  Substance-Related Disorders are commonly comorbid with many mental disorders, including Conduct Disorder in adolescents; Antisocial and Borderline Personality Disorders, Schizophrenia, Bipolar Disorder.  (American Psychiatric Association, Diagnostic and statistical manual of mental disorders, 2000, p. 204)   Schneier et al. (2010) also concluded that alcohol use disorders and social anxiety disorder (SAD) is a prevalent dual diagnosis, associated with substantial rates of additional co-morbidity.

ADHD represents a risk factor for substance abuse.  ADHD patients with a high degree of nicotine consumption may be consuming large quantities as a form of self-medication.  Nicotine and alcohol, when combined, pose a markedly greater risk for the development of other addictions.  (Ohlmeier et al., 2007, p. 542)  There is “high comorbidity between heavy drinking and heavy smoking.”  (Blaney & Millon, 2009, p. 266)  These admissions seem to support the premise that alcohol and nicotine continue to serve as “gateway drugs” for people whom suffer from ADHD.

“In terms of clinical presentation, a concurrent Personality Disorder (PD) diagnosis is associated with an earlier age of onset of alcohol-related problems, increased addiction severity, more secondary drug use, more psychological distress, and greater impairment in social functioning.  As for course in addiction treatment, a concurrent PD diagnosis has been associated with premature discontinuation of treatment, earlier relapse, poorer treatment response, and worse long-term outcome.”  (Zikos, Gill, & Charney, 2010, p. 66)  Cluster B (Antisocial, Borderline, Histrionic, and Narcissistic) Personality Disorders (PDs) appear to be particularly prevalent, perhaps because the link between substance dependency and antisocial behavior can be found genetically.  (Blaney & Millon, 2009, p. 263)

“Among individuals with schizophrenia, between 40% and 50% also meet criteria for one or more substance use disorders.”  (Blaney & Millon, 2009, p. 288)  Comorbid substance use complicates adherence to sometimes complex schizophrenia treatment regimens.  Poor adherence to treatment results in worsening of schizophrenia symptoms, relapse, worsening of overall condition, increased utilization of health care facilities, re-hospitalization, reduced quality of life, social alienation, increased substance abuse, unemployment, violence, high rates of victimization, incarceration, and death.  (Hardeman, Harding, & Narasimhan, 2010, p. 405-406)  The compounding effect of substance abuse on the quality of life for individuals with schizophrenia can’t be understated.  Substance abuse is particularly common and also worsens the course of schizophrenia.  (Buckley, Miller, Lehrer, & Castle, 2009, p. 396)

Differential diagnosis and treatment can sometimes be a troublesome proposition.  Comorbidity complicates the diagnosis, treatment, and clinical course of Substance Abuse Disorders (SUDs).  (Blaney & Millon, 2009, p. 287)  “If symptoms precede the onset of substance use or persist during extended periods of abstinence from the substance, it is likely that the symptoms are not substance induced.”  (4th ed., text rev.; DSM-IV-TR; American Psychiatric Association, 2000, p. 210)  Carbaugh and Sias (2010) concluded that successful outcomes can be increased through proper diagnosis and early intervention, at least in the case of comorbid Bulimia Nervosa and substance abuse.  Prevention of substance use disorders can help alleviate or decrease much impairment in psychiatric patients in particular.  (Powers, 2007, p. 357)  Furthermore, a review of treatments for patients with severe mental illness and comorbid substance use disorders concluded that mental health treatment combined with substance abuse treatment is more effective than treatment occurring alone for either disorder or occurring concurrently without articulation between treatments.  (Hoblyn, Balt, Woodard, & Brooks, 2009, p. 54)

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References

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author.

Blaney, P. H., & Millon, T. (2009). Oxford textbook of psychopathology (2nd ed.). New York, New York: Oxford University Press.

Buckley, P. F., Miller, B. J., Lehrer, D. S., & Castle, D. J. (2009, Mar). Psychiatric comorbidities and schizophrenia. Schizophrenia Bulletin, 35(2), 383-402. doi: 10.1093/schbul/sbn135

Carbaugh, R. J., & Sias, S. M. (2010, Apr). Comorbidity of bulimia nervosa and substance abuse: Etiologies, treatment issues, and treatment approaches. Journal of Mental Health Counseling, 32(2), 125-138. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=2026599321&sid=2&Fmt=3&clientId=4683&RQT=309&VName=PQD

Colman, A. M. (2009). Oxford dictionary of psychology (3rd ed.). Oxford, NY: Oxford University Press.

Hardeman, S. M., Harding, R. K., & Narasimhan, M. (2010, Apr). Simplifying adherence in schizophrenia. Psychiatric Services, 61(4), 405-408. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=2006767471&sid=3&Fmt=3&clientId=4683&RQT=309&VName=PQD

Hoblyn, J. C., Balt, S. L., Woodard, S. A., & Brooks, J. O. (2009, Jan). Substance use disorders as risk factors for psychiatric hospitalization in bipolar disorder. Psychiatric Services, 60(1), 50-55. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1654365811&sid=6&Fmt=3&clientId=4683&RQT=309&VName=PQD

Netherton, S. D., Holmes, D., & Walker, C. E. (1999). Child and adolescent psychological disorders: A comprehensive textbook. Oxford, NY: Oxford University Press.

Ohlmeier, M. D., Peters, K., Kordon, A., Seifert, J., Wildt, B. T., Weise, B., … Schneider, U. (2007, Aug). Nicotine and alcohol dependence in patients with comorbid attention-deficit/hyperactivity disorder (ADHD). Alcohol and Alcoholism : International Journal of the Medical Council on Alcoholism, 42(6), 539-543. doi: 10.1093/alcalc/agm069

Powers, R. A. (2007, May). Alcohol and drug abuse prevention. Psychiatric Annals, 37(5), 349-358. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1275282831&sid=5&Fmt=3&clientId=4683&RQT=309&VName=PQD

Schneier, F. R., Foose, T. E., Hasin, D. S., & Heimberg, R. G. (2010, Jun). Social anxiety disorder and alcohol use disorder co-morbidity in the National Epidemiologic Survey on Alcohol and Related Conditions. Psychological Medicine, 40(6), 977-988. doi: 10.1017/S0033291709991231

Shiel, W. C., Jr., & Stoppler, M. C. (Eds.). (2008). Webster’s new world  medical dictionary (3rd ed.). Hoboken, NJ: Wiley Publishing.

Zikos, E., Gill, K. J., & Charney, D. A. (2010, Feb). Personality disorders among alcoholic outpatients: Prevalence and course in treatment. Canadian Journal of Psychiatry, 55(2), 65-73. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1986429431&sid=1&Fmt=3&clientId=4683&RQT=309&VName=PQD

Schizophrenia, Downward Social Drift, and Interpersonal Adjustment


Everyday social encounters present people with schizophrenia a considerable amount of difficulty.  They show significant impairment in both “instrumental relationships” and social-emotional relationships.  This impairment is demonstrated by “downward social drift” and, perhaps more importantly, the fact that the majority of people with schizophrenia never marry.  Of note is that interpersonal adjustment issues are much more prevalent in the male portion of the schizophrenia population that in the female portion.

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Social competence is a global or “macro” measurement of social role performance.  Global social competence issues continue to be a marker not only for people who have schizophrenia, but for people who are considered “high risk.”  I still don’t quite understand the etiology of these social deficits however… which came first, the social deficits or the disorder?

Social skills are less global and more molecular, thereby representing skills that enable a person to competently perform a social task.  They include “specific verbal, non-verbal and paralinguistic (e.g., voice tone) behavioral components that together form the basis for effective communication.”  (Blaney & Millon, 2009, p. 335)  To my own personal delight, I really enjoy any opportunity to utilize role-play… and this is one of them.  Typically, people with schizophrenia will show weaker verbal and nonverbal skill development, they tend to be less assertive, and they tend to deny making errors or lie as opposed to apologize or explain.  I am really looking forward to utilizing role-play with this population, I believe it to be one of my strong suits (and one of the pieces I really enjoy).

People with schizophrenia can have remarkably impaired ability to solve social problems.  This might manifest in difficulty recognizing interpersonal problems, formulating solutions to that problem, or perhaps most importantly implementing a solution that has a probably degree of success.  They are generally less able to recognize poor problem solutions (e.g., solutions that are unlikely to work).

Gender is an often neglected variable when studying schizophrenia.  Female patients typically have later onset, shorter and less frequent psychotic episodes, and show better response to treatment when compared to make counterparts.  They are more likely to be marked, to live independently, and to be employed (despite having similar symptoms to men).  Women often require less antipsychotic medication to stabilize them.  This leads some authors to speculate about the neuroprotective properties of estrogen… interesting concept to say the least.  This might be off-base, but could this possibly explain the late life crisis that women often experience around menopause?

Positive and negative symptoms should not be viewed in the context of “good and bad.”  Positive symptoms are “added,” like delusions or hallucinations for example.  Negative symptoms are typically features that are removed, reduced, or blunted.  This typically manifests as emotional withdrawal or anhedonia.  Negative effects have been shown to predict both unemployment and reduced social network size.  In total, positive symptoms, negative symptoms, and “disorders of relating” represent three distinct dimensions of schizophrenia.  (Blaney & Millon, 2009, p. 340)

Of particular interest to me is the discussion on interpersonal stress, relapse, and the apparent foundation of the above in family systems theory.  Specifically, “the social environment into which schizophrenia patients were discharged after they left the hospital was significantly associated with how well patients fared psychiatrically over the next several months.”  (Blaney & Millon, 2009, p. 349)  Expressed emotion (EE) reflects the extent to which the relatives of a psychiatric patient talk about that patient in a critical, hostile, or emotionally over-involved way.  EE has been found to be a reliable predictor of relapse, and as a result, family therapy focused on dealing with living with a schizophrenic patient is definitely in order.  This can assist family members in overcoming their apparent difficulty in accepting, and understanding, the disorder.

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Reference

Blaney, P. H., & Millon, T. (2009). Oxford textbook of psychopathology (2nd ed.). New York, New York: Oxford University Press.