AAIM | 21st Century Medicine

The Journal of the American Association of Integrative Medicine

Disability and Forgiveness: An Intervention to Promote Positive Coping for Persons with Disabilities

Disability and Forgiveness: An Intervention to Promote Positive Coping for Persons with Disabilities

Susan Stuntzner, PhD, LPC, LMHP, CRC, NCC, DCC, BCPC, FAPA


Angela MacDonald, Med, CRC, NCC

Email: susan.stuntzner@utrgv.edu


Paper is based on a program presented at the 2016 American Counseling Association Conference, March 2016, Montreal, Canada.




Disability is an event that forever changes a person’s life.  Throughout the coping and adaptation process, many experience negative thoughts and feelings such as anger, anxiety, depression, and multiple forms of frustration.  Some of these may be related to a disability, while others are by-products of the negative experiences, attitudes, and treatment of persons with disabilities. These include societal barriers and injustices and changes and losses that often accompany a disability. Counseling professionals can assist persons with disabilities in learning to improve their coping process by learning about approaches and, in this case, interventions to help promote healing and positive coping.  In order to cultivate forgiveness, the present article clarifies the meaning of forgiveness and its relevance to persons with disabilities, discusses barriers to and benefits of forgiveness, and provides a rationale for developing the forgiveness intervention and information about the content and modules it contains.  Implications concerning ways counselors can use the forgiveness intervention and future directions for study are also discussed.

Learning Objectives

  • Increase professionals’ knowledge of forgiveness, barriers to forgiveness, and benefits of forgiveness.
  • Improve professionals’ understanding of the importance of forgiveness as it relates to the needs of people with disabilities.
  • Educate professionals about the proposed forgiveness intervention and its applicability to people with disabilities.
  • Discuss relevance of the intervention to professional practice and future directions for research.

Keywords: forgiveness, intervention, coping with disability, therapeutic approaches, counseling strategies, counseling

Program Level: Advanced

Target Audience: counselors, psychologists, social workers, case workers, and allied helping professionals who work with persons with disabilities in a therapeutic setting

Professionals reviewing this article are alerted to the notion that the proposed intervention is Phase 1 of its development.  The forgiveness intervention has not yet been pilot-tested, but Phase 2 of the research process includes the collection of data among people with disabilities.  The intent of this intervention is to provide professionals and people with disabilities a pathway to explore and work on forgiveness as it relates to the complexity of issues, hurts, and offenses that often accompany living with a disability.

Disability is a term often viewed and associated with negative thoughts, beliefs, and feelings, particularly for people who do not understand it or how the experience affects people and their loved ones.  Yet, for those who live with a disability, many learn to view it as simply a part of themselves along with a number of other personal and humanistic traits, rather than have it be the defining feature of who they are as a person (Stuntzner, 2012).  According to the American with Disabilities Act (1990), a person with a disability is someone who “has a physical or mental impairment that limits one or more major life activities.  Major life activities may include caring for oneself, performing manual tasks, walking, seeing, hearing, breathing, learning, and working” (Maki & Riggar, 2004, p. 7).  Under the ADA, numerous disabilities are covered including neurological, musculoskeletal, physical, sensory, respiratory, cardiovascular, mental, psychological, and emotional conditions.  Such a definition brings to our awareness that disability is a situation that can be quite complex, affecting people in numerous ways, and meaning different things to each individual.  Furthermore, it implies that a person’s life has changed to the extent that there is a major alteration in personal functioning.  This change in functioning, although not explicitly stated, is only one issue people with disabilities must address.  Many others issues, concerns, and hurts often not seen or discussed, such as the way people are treated by others or society (i.e., negative societal attitudes, unemployment, lack of access to resources) (Smart, 2009) are just as important and relevant to a person’s coping process.

Disability is an event that forever changes peoples’ lives and that of their loved ones. Many not familiar with disability or the way it changes peoples’ lives may believe that positive coping and healing is about accepting and adapting to the condition. However, the coping and adaptation process is much more involved and often consists of multiple layers of hurt and offenses, which must be addressed.  For instance, following a disability, people must learn to cope with the condition including: negative thoughts and feelings such as  self-criticism, grief, anxiety, depression, and blame (Boekamp, Overholser,  & Schubert, 1996; Bulman & Wortman, 1977; Livneh & Antonak, 1997; Stuntzner, 2014a; Turner & McLean, 1989); changes in personal functioning or loss due to the disability (i.e., cognition, mental capacities, physical abilities); alterations in personal relationships (Crewe, 1999; Somers, 1992); negative attitudes, bias, and treatment from others and society (Smart, 2009; Stuntzner, 2012); and personal losses related to the presence of disability (i.e., lack of family or spousal support, changes in the person now that disability is present) (Stuntzner, 2015b).  Similarly, some people may experience shattered world beliefs now that disability is present and anger towards oneself, others, or God (Lane, 1999).

As is evident, the possibilities for personal hurts, offenses, and changes are numerous following a disability.  Whilst some persons with disabilities learn to cope with and move past the disability and its associated life changes, many do not.  Some eventually figure it out but require more time and additional support (Marini, Glover-Graf, & Millington, 2012; Stuntzner, 2014b; Stuntzner & Hartley, 2014a).  Compounding the situation, is the reality that few interventions exist to help persons with disabilities figure out how to cope, adapt, and heal (see Stuntzner & Hartley, 2014b).  Similarly, there appears to be a void in the presence of forgiveness interventions specifically tailored to the needs, hurts, and personal experiences of persons with disabilities.

In an effort to explain forgiveness and its relevance to the coping, adaptation, and healing process of persons with disabilities, the authors discuss the meaning of forgiveness, barriers to and benefits of forgiveness, information about whether forgiveness is a skill or a process, relevance of forgiveness to disability, and the rationale for developing the forgiveness intervention.  In the remaining sections, information is presented about the intervention’s development and format, professional considerations, and future directions for research.

Defining Forgiveness

Over the past 25 years, forgiveness has become an area of increasing interest in psychology, counseling, and the allied helping professions. Yet, it has not been fully embraced or applied to the healing process of persons with disabilities (Stuntzner, 2008; Webb, 2007).  Since its conception and exploration throughout the literature, forgiveness has not been uniformly defined. However, many forgiveness scholars state that forgiveness is a skill or way of being that can be taught or cultivated and is a process that involves the reduction of negative thoughts, feelings, and behaviors and the increase of positive ones (Enright & Fitzgibbons, 2000, 2015; North, 1987; Thorensen, Luskin, & Harris, 1998).  According to Enright (2001), forgiveness involves a change in how a person views, feels, and behaves towards to offending person and such a change leads to an attitude of compassion and understanding.  Learning to be more compassionate towards another person, particularly someone who has caused emotional or psychological pain and hurt, can lead to the practice of self-compassion and acceptance of oneself and situation (Stuntzner & Dalton, 2014).

Forgiveness has often been described as something that happens between two or more people (Enright, Freedman, & Rique, 1998). However, it is the authors’ premise that in some instances there may be the need to forgive oneself (Enright, 1996), God, and the understanding that God did not cause something to happen (Stuntzner, 2008, 2015c), or events and situations, especially those that happen on a repeated basis (i.e., continued negative treatment of persons with disabilities by society) (Stuntzner, 2015c; Stuntzner & MacDonald, 2014b).  In situations such as the last point mentioned, forgiveness may involve the inclusion of “multiple people or parties (i.e., agencies, organizations, legislative acts)” as these events continue to happen, are not the result of only one individual, and may be the representation of an environmental attitude or system within an organization or business (Stuntzner, 2015c, p. 15).

Regardless of the working definition, professionals interested in facilitating forgiveness work among persons with disabilities are encouraged to explore the meaning and importance of forgiveness from their perspective and values (Stuntzner, 2015c).  Conceptualizing forgiveness in a personal and meaningful manner can help people gain clarity about what forgiveness means and looks like to them and can be the start of learning to value and personalize the process of forgiveness.  Having a personal investment in forgiveness can assist people in moving forward when they experience difficulties forgiving someone, as it is not easy to forgive when deep hurt has occurred.

Barriers to Forgiveness

Learning to forgive can be impeded or slowed by the presence of barriers.  Barriers can be understood as those internal parts of ourselves that create additional hurdles and obstacles to address and overcome (Stuntzner, 2015b) prior to reaching the benefits and positive outcomes of forgiveness.  People may not be aware of the ways they prevent themselves from forgiving. Thus, an important part of learning to forgive may involve the need to identify and reduce the barriers that exist (Stuntzner, 2015c).

Counselors working with persons with disabilities may find it beneficial to explore individualized and self-created barriers as a part of the forgiveness process.  Understanding one’s own self-imposed barriers to forgiveness is important as they can complicate an already difficult situation, influence peoples’ thoughts, feelings, and behaviors, as well as their ability to heal (Stuntzner, 2015c).  Common barriers that can impede peoples’ ability to forgiveness are discussed throughout the proposed forgiveness intervention and may include the following (see Stuntzner, 2015c, pp. 19-20 for full review):

  • Holding in and suppressing negative feelings towards oneself and others (Kendall, 2007; Tutu & Tutu, 2004).
  • Blaming yourself, others, or God,
  • Feeling self-righteous or filled with self-pity (Kendall, 2007),
  • Thinking it is weak to forgive (Tutu & Tutu, 2014),
  • Being afraid of what will happen if a person lets go of the hurt.
  • Believing one cannot let go of the past.
  • Feeling hopeless or apathetic.
  • Waiting for another person to recognize the error of one’s ways.

Benefits of Forgiveness

Counselors interested in exploring forgiveness with their clients may find it helpful to familiarize themselves with the benefits of forgiveness.  Having a foundation of the ways it can improve peoples’ lives is essential, because forgiveness is not always an easy task.  Furthermore, some people may want to forgive, but remain skeptical it will help or that it is worth the effort. Some people may be stymied in their ability to forgive because they are unsure of what it is or how to achieve it.  Still others are likely to “know” that forgiving helps but they have become detached or distant in their ability to truly remember the power and healing effect of forgiveness. For these reasons, counselors can approach forgiveness from an educational or enlightening perspective and assist individuals with disabilities in learning about the benefits of forgiveness and the ways it can help them.

Forgiveness can improve peoples’ lives in any number of ways.  More specifically, forgiveness can help people reduce anger and resentment (McGary, 1989), decrease the tendency to hurt themselves or others (Fitzgibbons, 1986), reduce one’s desire for revenge against the offending person (Fitzgibbons, 1998), and change their adjustment to disability process so they experience fewer negative emotions as it relates to their disability (Stuntzner, 2008).  Forgiveness can also help people improve their relationships with themselves and others, enhance one’s satisfaction with life because they are no longer bound to the past, feel more serene and peaceful, and improve their ability to face and deal with their inner pain (Romig & Ventra, 1998).  Forgiveness can also help people become stronger and more confident because through learning forgiveness, people realize they can do more than survive.  Oftentimes, people discover they have the ability to heal and emerge as a new, and perhaps a better individual than previously imagined, and they learn to ascribe meaning to their experiences (Frankl, 1959; Smedes, 1996; Stuntzner, 2015c).  This process can lead to much insight and personal growth.

Understanding Forgiveness as a Skill and a Process

Professionals who counsel persons with disabilities may wonder if forgiveness is a skill practiced or a process through which a person proceeds to achieve it.  The authors propose that it may be either one, depending on how forgiveness is conceptualized and cultivated (Stuntzner, Dalton, & MacDonald, 2015).  Much of the existing research by Enright and colleagues (Coyle & Enright, 1997; Enright et al., 1998; Enright & the Human Development Study Group, 1991; Hebl & Enright, 1993; Lee & Enright, 2014; Lin, 2001; Osterndorf, Enright, Holter, & Klatt, 2011; Stuntzner, 2008) describe forgiveness as a process since it takes time to forgive, and people learn skills through a series of phases or steps that can be applied to their hurts and offenses (Enright, 2001).

One well-studied forgiveness model developed by Enright and colleagues (1998) is a forgiveness process model that consists of four phases: the Uncovering Phase, the Decision Phase, the Work Phase, and the Deepening Phase.  According to this model, during the Uncovering Phase, people learn to recognize negative thoughts and feelings that exist due to a lack of forgiveness and the impact of these on the individual.  Following, people who want to pursue forgiveness may decide a change is needed within them for this to occur, thus, this inner awakening helps them make a decision or commitment to forgive (i.e., the Decision Phase). Next, in the Work Phase, people further examine their hurts and offenses in relation to the offender and work on re-framing the offender and the offense so they can release the negative thoughts and feelings and begin to replace them with more compassion, understanding, and caring.  In the Deepening Phase, people learn how to bear the pain, understanding that they are not alone and isolated in their experience, and they find meaning in their experiences (Enright & the Human Development Study Group, 1991).

Forgiveness may also be conceptualized and practiced as a skill (Stuntzner et al., 2015a). From this perspective, forgiveness may be introduced or practiced as a part of an intervention that teaches coping skills.  For example, Stuntzner and Hartley (2014b) developed a resilience-based skill intervention that teaches and cultivates specific skills found to be associated with resilience.  One of the modules in this intervention discusses and addresses forgiveness as a skill that can be learned and, later, refined to help people be more resilient.  Related is the notion that some people may learn specific skills such as self-compassion, mindfulness, or compassion and through the practice of these skills learn about forgiveness (Stuntzner et al., 2015a). Third and also of importance is the fact that some people may have difficulty forgiving. In these instances, it may be helpful to work with people on learning how to forgive themselves and to achieve some success in being able to do so before approaching forgiveness as a process or a way of life.

Application of Forgiveness to Disability

Forgiveness has rarely been considered, conceptualized, or applied to the context of disability. Yet, it appears to be very applicable to the experience of and to the needs of persons with disabilities (Stuntzner & Dalton, 2015).  Disability is an experience or a situation that is often associated, directly or indirectly, with negative thoughts, beliefs, feelings, and events (i.e., blame, self-blame, criticism, anger, anxiety, depression, shame, loss of what was to be, negative treatment, bias, or discrimination).  Throughout the coping process of learning to adapt to the disability and long after the moment has initially occurred, persons with disabilities are presented with events, people, and situations that challenge a person’s coping ability or, in many instances, reignite unpleasant thoughts, and feelings which must be addressed and worked through to maximize coping.  Further, through the process of living with a disability, people often discover their worldview or beliefs about life, fairness, and God have been shattered and must be rebuilt.  Other times, it may be the beliefs and views of their family that have been drastically altered and in needs of healing.

Forgiveness has much relevance for persons with disabilities, as there are multiple ways and contexts in which a person’s life has been affected, altered, or changed and to which forgiveness may be applied.  More specifically, persons with disabilities may feel the need to forgive:  (a) oneself, if the person feels he or she has done something to harm oneself in a destructive manner, or another (Luskin, 2002); (b) God or a higher being (Lane, 1999); (c) people who have committed offenses towards persons with disabilities and the offenses are directly related to the disability; (d) employers or societal offenses that convey a definite lack of acceptance (i.e., bias,  stigma, lack of opportunities); (e) friends or family who cannot accept the disability and its associated changes; (f) collective hurts and offenses comprised of nameless faces  which represent a  series of hurtful, derogatory, and repeated events (Stuntzner, 2012; Stuntzner & MacDonald, 2014b); and (g) medical professionals who made a serious mistake and caused further injury to the person and the disability (see Stuntzner, 2015c for a full review). Similarly, persons with disabilities may report and discover a number of people and situations they need to forgive and several of the stated hurts and offenses may occur long after the initial onset of disability.  For instance, Stuntzner (2008), in her forgiveness and coping study among persons with spinal cord injury, found that participants reported the need to forgive intimate partners and spouses, the person who caused the injury, employers, caregivers, oneself, friends of the same or opposite gender, and relatives.  Additionally, some participants reported the need to forgive “other” people than those initially recognized as they went through the forgiveness intervention.

Rationale for Forgiveness Intervention

In the past decade or so, due to the influence of the Positive Psychology movement, there has been a burgeoning of interest and information on positive factors and traits associated coping and moving past difficult life events.  Included throughout is the need to better understand issues such as forgiveness, compassion, self-compassion, mindfulness, gratitude, spirituality, resilience, and post-traumatic growth (see Marini & Chacon, 2012; McCullough, Root, Tabak, & Witvliet, 2009; Watkins, Van Gelder, & Frias, 2009) as well as the study of factors that promote positive well-being (i.e., forgiveness, attitude and outlook on life, and spirituality).

Additionally, the psychology profession and some allied professions have embraced the study and importance of forgiveness in helping people heal and move beyond serious hurts and offenses.  Intervention forgiveness studies have been conducted among a number of populations including elderly women (Hebl & Enright, 1993), persons and families dealing with substance abuse issues (Lin, 2001; Osterndorf et al., 2011), partners of people who chose to have an abortion (Coyle & Enright, 1997), adult incest survivors (Freedman & Enright, 1996), persons with spinal cord injury (Stuntzner, 2008; Stuntzner, Hartley, Lynch, & Enright, 2015), and women with fibromyalgia who experienced childhood abuse (Lee & Enright, 2014), just to name a few.  Forgiveness intervention studies have consistently demonstrated an ability to help people reduce negative emotions (i.e., depression, anger, anxiety) and promote positive emotions instead.  Additionally, many studies indicate that forgiveness helps increase self-esteem (Enright & Coyle, 1998) and hope (Freedman & Enright, 1996), and affects adjustment to disability (Stuntzner, 2008; Willmering, 1999). More recently, research suggests that forgiveness may be a factor that improves peoples’ health (Webb, Toussaint, Kalpakjian, & Tate, 2010) and is associated with important characteristics such as resilience (Farley, 2011).

Despite this increased study and interest in forgiveness, very few forgiveness intervention studies have been focused on persons with disabilities and their needs.  Similarly, there appears to be a void of forgiveness interventions specifically tailored to the hurts and offenses that may be related to the presence of disability and the experiences of persons with disabilities.  The focus of the intervention is tailored to address this void and the content provided throughout is directed at learning about forgiveness in the context of living with a disability.

Another point worthy of mention and as a key factor in the development of the proposed intervention, is participant data related to forgiveness and the desire of persons with disabilities to learn more about forgiveness.  Stuntzner and MacDonald (2014a, 2014b) conducted two pilot studies on a 10-module resilience intervention for persons and women with disabilities. Participants were comprised of people living with “Post Traumatic Stress Disorder (PTSD), anxiety, bipolar, depression, fibromyalgia, chronic pain, lupus, narcolepsy, kidney failure, arthritis, and gout.  Some participants lived with multiple conditions” (Stuntzner & Hartley, 2014, p. 8).  Participants were exposed to forgiveness as a part of the modules and during the process, they indicated it would be helpful to learn more about forgiveness, and have more time to work on or explore it further.  Additionally, some found it really difficult to forgive or work on it as a part of their healing process, although they indicated they wanted to.  For this reason, the first author felt it was necessary and important to develop and empirically study a forgiveness intervention that was specifically tailored to the coping and adaptation needs and issues of persons with disabilities.

Format of Forgiveness Intervention

The proposed forgiveness intervention is a 141-page training manual and is comprised of seven logically and strategically ordered modules to guide facilitators and participants through the intervention.  Due to the depth of the intervention, the authors are not able to cover it entirely throughout this article, but counseling professionals are welcome to contact the first author should they have questions or want to know more about the intervention.  Additionally, the forgiveness intervention is intended to be offered at a future date following CEU approval, as a process or as separate forgiveness modules, which may be selected as training components. Information and modules will be available on the first author’s website,  Healthier Living Following Disability.

While developing the proposed intervention, a thorough review of the forgiveness literature was conducted and matched with information and research that is associated with positive coping and adaptation following disability.  Since forgiveness has rarely been applied to the needs and coping process of persons with disabilities and the minimal research and literature that is available suggests that forgiveness may be helpful (Stuntzner, 2008; Stuntzner et al., 2015a; Webb, 2007; Willmering, 1999), the authors felt it would be of value to consider and include information, content, and exercises that mirror a combination of the two areas and infuse components of spiritual practices (i.e., self-compassion, compassion, mindfulness, ways forgiveness improves a person’s life).  Additional support for the need to include spiritual practices is discussed throughout the professional literature, given the fact that spirituality and spiritual practices are well-known factors found to improve the coping process of persons with disabilities.

Modules are ordered and presented in a sequential fashion where each one builds upon the previous module. This “building” and sequential process is to help lay the foundation for participants to learn about forgiveness, decide for themselves what it means to forgive, how they know they have forgiven, and its relevance to the needs of persons with disabilities. Additionally, participants are given the opportunity to identify barriers and issues that either prevent or inhibit their ability to forgive or, at a minimum, to release the hold their negative thoughts and feelings may have on them.  They are also encouraged to explore meaning-making as it relates to their disability.  All of these areas are covered in the first module and set the foundation of exploring forgiveness and its applicability to persons with disabilities before proceeding into the modules that follow.  Also of importance is to note that the second module, as listed below, was initially developed to address specifically the needs of women with disabilities, as this is a particularly vulnerable and unattended population throughout research and society.  Having said that, the cross-over between the needs of men and women with disabilities is vast, Thus, counseling professionals may still find much of the information useful and applicable to men, as well as to women.  Collectively, the seven modules covered throughout the intervention are as follows (pp. 3 – 90):

  1. Forgiveness and its Applicability to Disability
  2. Women with Disabilities and their Experiences
  3. Understanding the Benefits of Forgiving and the Costs of not Forgiving
  4. Identifying if a Person is Ready and Willing to Forgive
  5. Forgiveness Cultivation Strategies
  6. Determining Personal Progress in Moving Towards Forgiveness
  7. Review of the Skills and Modules for Future Practice

The forgiveness intervention was originally designed so that it may be presented as a group intervention, although counseling professionals may find it helpful to consider specific exercises when working with individuals and/or groups.  The overall format of the intervention provides opportunities for people to learn, participate, share their own experiences, and receive psycho-educational instruction about: (a) forgiveness; (b) forgiveness as it relates to the specific thoughts, feelings, and experiences of disability; (c) self-assessment exercises to increase awareness of personal beliefs, feelings, and behaviors; (d) the interrelationship between an individual’s thoughts, feelings, and behaviors and positive or maladaptive coping (i.e., willingness to consider forgiveness vs. resistance); (e) selecting a focus or person to whom they may want to apply forgiveness to; (f) exploration of the impact of forgiving versus not forgiving; (g) identification if forgiveness is the right choice to pursue at this moment; (h) personal beliefs and expectations about forgiveness and what a person hopes it brings to them; (i) forgiveness building skills and exercises (i.e., mindfulness, compassion, self-compassion, previously used skills that helped them forgive, weekly personal goals and action plan activities); and (j) periodic assessment of personal progress made towards forgiveness.  At the conclusion of the intervention, participants have an opportunity to review comprehensively what they have learned and to share their own narratives and personal story of the progress they feel has been made.  A part of this process may include identifying the positive changes they made within themselves, or those others have noticed, sharing what they learned about forgiveness, identifying what was helpful and what was not as a part of their forgiveness journey, followed by determining how they want to further their practice and integration of forgiveness.

The proposed forgiveness intervention differs from other forgiveness approaches in that it exposes and educates people to forgiveness in the context of living with a disability.  Although other forgiveness interventions exist (see Enright, 2001; Worthington, 2006), many are focused on helping people forgive when hurt and offenses have occurred in a more humanistic, global sense.  While these approaches are valid and very useful, they do not understand disability or apply the concept of forgiveness to the experience of disability which is often a multi-layered event that changes peoples’ lives in numerous ways.

Stuntzner’s Forgiveness Intervention (2015c) teaches people about forgiveness and its applicability to disability and the common hurts and offenses that occur while living with a disability.  Each module is presented in a way that people have the opportunity to apply the information learned to their life with a disability and to their unique set of circumstances. Additionally, the intervention provides content and exercises more specifically geared towards women with disabilities and their unique set of experiences (i.e., Module 2).  To date, existing forgiveness interventions do not appear to consider the potential differences in experiences and needs that occur for women or women with disabilities.  Another way the forgiveness intervention differs from other approaches is in relation to some of the strategies used to explore and promote forgiveness.  For example, each module contains self-assessment exercises that serve as an impetus for people to examine how well they are doing and coping in relation to each module topic.  Furthermore, as a part of Module 5, Strategies to Promote Forgiveness, people are exposed to concepts and skills they can cultivate such as mindfulness, compassion, and self-compassion.

Professional Implications for Practice

Due to the magnitude of hurts and offenses often experienced by persons with disabilities, regardless of the disability type, the forgiveness intervention was developed for people living with various types of disabilities including physical, neurological, degenerative, mental, and emotional conditions.  Counselors interested in exploring and teaching people with disabilities about forgiveness and its therapeutic value are encouraged to consider if the people they serve are ready and willing to pursue forgiveness and have the cognitive ability to complete the exercises.  Although forgiveness is of value to everyone, and to anyone living with a disability, it is not an easy task or process to work on when deep hurt and offenses have occurred.  For that reason, it is essential to work with people and determine if they are ready to forgive and do the work.  Having said that, it is also important to have a sense if people have the mental and cognitive ability to understand forgiveness and the proposed exercises to achieve maximum benefit.  When this is not the case, counselors may want to consider ways they can tailor the information and exercises to meet their clients’ needs.

Counselors wanting to implement forgiveness therapy and interventions as a part of their practice are encouraged to increase their understanding of forgiveness, since this topic is not always easy for people to understand the magnitude and all that is involved.  Counselors can enhance their understanding of forgiveness by attending training and seminars offered through their professional organization, conferences (i.e., ACA, Executive Summit), and by reading books (i.e., Forgiveness is a Choice: A Step-by-Step Process), reviewing self-study videos, and websites (i.e., www.internationalforgiveness.com/).  Counselors may also contact the first author if they are interested in learning more about the proposed intervention and the possibility of continuing education credits (CEUs). Having a thorough understanding of forgiveness is essential, as it is a topic that is likely to look and be different for each individual.  Thus, the more knowledge, information, and insight counselors have into forgiveness from multiple perspectives, the more comfortable they are likely to be in approaching it with the people they serve.

Future Directions

As indicated earlier, the presented forgiveness intervention is Phase 1 of the research process.  Presently, the first author is in the course of getting ready to conduct an investigation and pilot-test the intervention among persons with disabilities.  Phase 2 of the process is intended to examine its utility among individuals with disabilities who are a part of a combined gender group and among women with disabilities.  The first study aims to acquire an understanding of the forgiveness intervention and how it helps persons with disabilities learn to forgive and improve their overall functioning and well-being (i.e., decrease negative thoughts and emotions).  From this process, data can be collected to help determine if it adequately addresses the specific needs and issues of persons with disabilities as these relate to forgiveness. Adjustments to various modules are required, as well as learning more about its effectiveness in helping people forgive.  The second study that primarily focuses on the needs and forgiveness process of women with disabilities is of interest, given that much less is known about women with disabilities and their individual, personal, and coping needs than men.  As a result, research and information are minimal and somewhat lacking when it comes to the personal and coping needs of women with disabilities (Nosek, 2012).  Additionally, existing research suggests that women with disabilities are more willing to explore and participate in forgiveness studies compared to their male counterparts (see Rainey, Readdick, & Thyer, 2012).  For this reason, it behooves the authors to consider initial and separate pilot-test studies comprised of mixed-gender and female participants.  Participants should be recruited from agencies that serve persons with disabilities (i.e., Centers for Independent Living, Department of Vocational Rehabilitation Division, mental health agencies, and university services for students with disabilities) and the community as a whole.

The intended goal of the intervention is to determine if it serves persons with disabilities and provides them with a safe and secure platform to consider, explore, and cultivate forgiveness.  This process is so that further studies are completed by specific groups such as persons with spinal cord injuries, post-traumatic stress disorder, veterans, and other persons with disabilities who feel they have been greatly offended and hurt.  Hopefully, the proposed forgiveness intervention can be applied amongst people from ethnic minority groups as well.  The collection of further information relating to the spiritual and/or religious beliefs of persons with disabilities is also important.  As more information about forgiveness is collected, particularly pertaining to the relationship between people with disabilities and their needs, it is our hope that professionals in hospitals, treatment settings, vocational support programs, and the community can utilize and implement the forgiveness intervention in their work with persons with disabilities.


Forgiveness is highly applicable and relevant to people with disabilities and can be used as a means to reduce negative thoughts and feelings and to promote forgiveness and positive coping. Yet, forgiveness has been minimally studied among this group of individuals.  Persons with disabilities who learn to forgive are likely to experience many positive benefits that can assist them in also improving their coping and adaptation abilities (Stuntzner, 2008) and quality of life.  In an effort to assist professionals and persons with disabilities in learning more about forgiveness, its applicability to persons with disabilities, and ways to cultivate forgiveness, a seven-module forgiveness intervention has been developed.  It is the authors’ hope that both parties can access and utilize the proposed forgiveness intervention to further the practice and implementation of forgiveness.



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About the Authors

Dr. Susan Stuntzner, PhD, LPC, LMHP, CRC, NCC, DCC, BCPC, DAPA, FAPA, is an Assistant Professor in the School of Rehabilitation Services and Counseling at the University of Texas Rio Grande Valley. She currently trains students to become rehabilitation counseling professionals and to work directly with individuals with disabilities in numerous employment settings. Her research interests include: adaptation and coping with disability, resiliency, self-compassion and compassion, forgiveness and spirituality, development of intervention techniques and strategies, and mentorship of professionals with disabilities. She has written three books pertaining to coping and adaptation and/or resilience-based skills. Her works are entitled, Living with a Disability: Finding Peace Amidst the Storm, Reflections from the Past: Life Lessons for Better Living, and Resiliency and Coping: The Family After.  Dr. Stuntzner has researched and written articles on self-compassion and forgiveness and their potential relationship to the needs of individuals with disabilities. She has also developed two interventions (i.e., resilience, forgiveness) for persons with disabilities to assist them in their coping process. These works are entitled, “Stuntzner and Hartley’s Life Enhancement Intervention: Developing Resiliency Skills Following Disability” and “Stuntzner’s Forgiveness Intervention: Learning to Forgive Yourself and Others”.  Additional information can be found on her website: www.therapeutic-healing-disability.com. Questions concerning this article can be directed to her via email: susan.stuntzner@utrgv.edu.


Angela MacDonald, MEd, CRC, NCC, is an adjunct faculty member for the University of Idaho. She also works at the Disability Action Center, a center for independent living in Post Falls, Idaho. Angela works as an independent living specialist and transition manager for persons with disabilities who would like to further their independence and transition back into the community. Her passion in forgiveness research started in her graduate studies at the University of Idaho. While there, she had the opportunity to work with her professor, Dr. Susan Stuntzner, on research pertaining to resiliency and coping. She has co-facilitated two resilience intervention studies with Dr. Stuntzner; one was among a mixed gender group and the other was a resilience intervention study for women with disabilities. Throughout these studies, one of the modules focused on spirituality and forgiveness. She hopes to continue research work on forgiveness, as well as in the areas of resiliency and compassion. Angela’s background and training position her well to work with persons with disabilities in a research, rehabilitation, and mental health counseling context.

Ya Can’t Beat Beets

Ya Can’t Beat Beets

by Tammera J. Karr, PhD, DAAIM, BCIH, BCHN, CGP, CNC, CNW, CNH

What are your memories of beets? Mine are enjoying sugar, canned and pickled beets, with a side of greens on the plate. For me, the greens were sometimes, and still are, the only edible part of the plant, but as a kid I had family members who loved beets in all their forms.

Like many modern vegetables, beetroot was first cultivated by the Romans. By the 19th century it held great commercial value when it was discovered that beets could be converted into sugar. The Amalgamated Sugar Company was founded in 1897 in Logan, Utah, and is now located in Boise, Idaho. The company markets its sugar under the White Satin brand. As the Minidoka Irrigation Project of Idaho was nearing completion in 1912, Amalgamated Sugar moved its failing sugar plant from La Grande, Oregon to Burley, Idaho. The new location was chosen partly due to farmer land commitments and a connection to the Oregon Short Line Railroad Company. The first year of the Burley factory had higher production than any of the previous fourteen years in La Grande.

By the 1950s, White Satin Sugar was in every grocery store in the Pacific Northwest. The company was listed on the New York Stock Exchange in 1950. A new Portland, Oregon distribution center was finished in 1951 where the distribution silo could hold 2500 tons of sugar and supply it as bulk, liquid, blend, or packaged sugar.

Today’s leading producers of sugar are noted in the table below, in metric tons:

Table 1

Brazil  23,177
Western Europe(including EU-15)  18,679
India  18,491
China  9,419
United States  7,552


The total percentage of sugar production value in the United States reported in 2004 equaled only 1,928 million and 2.39% of the crop; (the biggest source being from corn).

Many classic beetroot recipes are associated with Central and Eastern Europe, including the famous beetroot soup known as borscht. Belonging to the same family as chard and spinach, both the leaves and root can be eaten, the leaves have a bitter taste while the round root is sweet. Typically, a rich purple color, beetroot can also be white or golden. Due to its high sugar content, beetroot is delicious eaten raw, but is more typically cooked or pickled.

Beetroot is of exceptional nutritional value, especially the greens. They are rich in calcium, iron, and vitamins A and C. Beetroots are an excellent source of folic acid and a very good source of fiber, manganese, and potassium. The liver loves beets for detoxing harmful chemicals from the body. The greens should not be overlooked, they can be cooked up and enjoyed in the same way as spinach.

Beets are a unique source of phytonutrients called betalains. Betanin and vulgaxanthin are the two best-studied betalains from beets. Both have been shown to provide antioxidant, anti-inflammatory, and detoxification support. Although you can see these betalain pigments in other foods like the stems of chard or rhubarb, the concentration of betalains in the peel and flesh of beets gives you an unexpectedly great opportunity for these health benefits.

An estimated 10-15% of all American adults’ experience Beeturia (a reddening of the urine) after consumption of beets in everyday amounts. While this phenomenon is not considered harmful in and of itself, it may be a possible indicator of problems with iron metabolism. Individuals with iron deficiency, iron excess, or specific problems with iron metabolism, are much more likely to experience Beeturia than individuals with a healthy iron metabolism.

So if you love or even like beets, summer is a great time to enjoy those sautéed beet greens, pickled beets or a beet salad.

To Your Good Health, and Colorful Foods.

Originally published July 30th, 2014, in Minerals & VitaminsEat for Health.

When Our Patients Request to Pray

When Our Patients Request to Pray


Cheryl Ann Green, PhD, DNP, RN, LCSW, CNL, FAPA, MAC

Assistant Professor of Nursing, Southern Connecticut State University

Adjunct Professor, University of Bridgeport

Off-Shift Nurse Leader, Yale-New Haven Hospital/ Yale Psychiatric Hospital

Email: greenc16@southernct.edu  and cagreen2271@sbcglobal.net

Phone: (203) 230-2427

Complementary Care

Over the past ten years of clinical practice, I have personally seen a resurgence in requests for patients of all faiths desiring prayer before medical and surgical care, as well as during therapy for treatment of anxiety, grieving, and relational problems. In my work as a licensed clinical social worker and registered nurse, crisis is often the reason people seek spiritual support.

According to Anderson & Worth (1997), “Spirituality refers to the uniquely personal and subjective of a fourth dimension; religion refers to the specific and concrete expression of spirituality” (p. 4). As human beings, our reality is comprised of what we see, how we interact with what we see, and how our surroundings impact us emotionally, physically, mentally, and spiritually. In absence of our natural human existence on Earth, we seek to find understanding of our longevity and brevity of life. Crisis, be it a diagnosis of illness, a death of a loved one, a divorce or breakup, stresses of school or work, our children, friends or spouse experiencing difficulties in their lives, it is complex and at times, seemingly unforgiving.

Our lives, as well of those of the patients we serve, must be open to that which we cannot clearly define, and still seek to qualify and quantify—the spiritual self. Integrating our patients’ spiritual and religious beliefs into their health and mental healthcare (Kahle & Robbins, 2004) is empowering for them and creates a dynamic holistic perspective to complementary care. Potter, Perry, Stockert, and Hall (2013) note that “The relationship between spirituality and healing is not completely understood. However, the individual’s intrinsic spirit seems to be an important factor in healing. Healing often takes place because of believing” (p. 691). It is therefore important for providers to address the spiritual health needs of patients, prayer being one facet. So, the next time a patient requests you to pray with them, be open-minded, and explore your own inner convictions and beliefs. Then, consider this complementary care as a means to further aid your patients in their emotional, physical, and spiritual healing.




Anderson, D.A. & Worthen, D. (1997). Exploring a fourth dimension: Spirituality as a resource for the

couple therapist.  Journal of Marital and Family Therapy, 23, 3-12.

Kahle, P.A. & Robbins, J.M. (2004). The power of spirituality in therapy: Integrating spiritual and religious

beliefs in mental health practice. Binghamton, NY: The Haworth Pastoral Press.

Potter, P.A., Perry, A.G., Stockert, P.A., & Hall, A.M. (2013). Fundamentals of nursing (8th ed.). St. Louis,

MO: Elsevier|Mosby.


About the Author

Cheryl Green, PhD, DNP, RN, LCSW, CNL is a nurse, clinical social worker, and clinical Christian counselor. In nursing, Dr. Green has worked in the areas of medical-surgical nursing, legal nurse consulting, psychiatry, community health, medically-complex rehabilitation, and as a nurse educator. As a social worker, she a had private practice working with children, families, and couples, served as a mental health consultant to a private school, provided spiritually-based therapy in a group practice, and   provided play therapy and child-centered family work with children affected and infected with HIV/AIDS. She has also worked as a crisis clinician providing on-call psychiatric consultation within a hospital setting.

Dr. Green presently works as a nurse leader at Yale-New Haven Hospital and is an assistant professor in the Department of Nursing at Southern Connecticut State University. Her volunteer work includes:  the American Red Cross Disaster Responder team, and the Billy Graham Evangelistic Association, as a Rapid Response Team Chaplain.

Sexual Revolution or Sexual Repression – What’s Going On?

Sexual Revolution or Sexual Repression – What’s Going On?

By Erica Goodstone, PhD, LMHC, LMFT, LPC

Are we on the verge of a new sexual revolution?  Are we already experiencing a sexual revolution?  Or is society becoming more restrictive, even at the same time that sexuality seems to be exploited in the media?  Yes, we have a real need for sexual reawakening.  I am not so sure about whether we are having a sexual revolution, but some sexologists believe we are.  In fact, in many ways, the topic of sexuality has become increasingly repressed while our conversations and teachings have become more restrictive.

Welcome to the Sexual Reawakening Virtual Summit beginning June 6, through June 26, 2016.  This is no ordinary summit.  First, you can have your own front row seat in your living room, office, or bedroom.  It is a virtual event, but this is no ordinary virtual event. I have brought together many leading sexologists including researchers, educators, therapist trainers, therapists, medical professionals, and authors. They each share their own unique expertise, advise, and perspective on this vast, important, and often neglected topic.

Our sexuality and our love map – our sexual needs, desires, fantasies, and behaviors – reveal who we are as a man or a woman and as a sensual living human being.  When our sexuality is working reasonably well, when our needs and desires fit comfortably within an established society norm, then sexuality seems to occupy a rather minor part of our daily living experiences.  When we feel emotionally connected, intimate with a partner we love, and we feel sexually content, then sexuality seems to not be such a big deal, but simply a part of life.

When our sexuality is not working well, it can become our number one priority, interfering with and even destroying our relationships, business pursuits, financial assets, and more.  When we have an apparent sexual dysfunction, when our sexual desires and behaviors do not fit the norm, when we are abusing or being abused by others, or when we feel frustrated, unsatisfied, and misunderstood, reawakening our capacity for intimacy and getting a handle on our sexuality can be essential for healthy living.

Each professional sexologist speaking on the Sexual Reawakening Summit will provide insights, information, research, or some valuable tips and suggestions for healing, improving, and enjoying intimate sexuality.  Sexuality seems to appear everywhere in the media, helping companies to sell all sorts of products and services. However, when it comes to understanding and healing the real sexual problems and concerns of real men and women, professional sexologists can provide the help that is needed.

Here is the link to join the free Sexual Reawakening Summit:  http://budurl.me/ReawakeningSummit

AAIM Member Highlight May 2016

AAIM Member Highlight May 2016

Dr. Lindsey Behlen, DOM, FAAIM


lindseybehlenDr. Behlen studied at the University of Wisconsin-Oshkosh and the University of Cambridge for her undergraduate studies of Biological Sciences. She graduated with her medical training from Texas Health & Science University. During the course of her Medical training she specialized in Pain Management and Sport’s Medicine. At Concordia University Dr. Behlen treated athletes and completed her Sport’s Medicine training. Her boards were completed in San Antonio, Texas – Medical Branch. While in San Antonio she spent time treating athletes in the NBA. With over a decade and a half of working in the healthcare field, Dr. Behlen found a calling in Integrative Pain Management. She also has a large fertility patient population. Dr. Behlen is a Fellow with the American Association of Integrative Medicine® (FAAIM). She has appeared on the nationally syndicated NBC show, Dr. OZ, as a physician commentator. She is also on the National Pain Advisory Board for Chronic Migraines. As of 2014 she is one of the newest elected Board Members of the American Association of Integrative Medicine. She is a Diplomate in the College of Physicians (DCP), Diplomate in the College of Pain Management (DCPM), Diplomate in the College of Pharmaceutical & Apothecary Sciences (DCPAS), and Diplomate in the College of Acupuncture & Neuromuscular Therapy (DCANT). She holds the highest National board certification for Acupuncture & Oriental Medicine (NCCAOM). Dr. Behlen is a member of American Association of Physicians & Surgeons, American Association of Integrative Medicine, American Chronic Pain Association and American Pregnancy Association. Currently Dr. Behlen is the only Doctor in the state of Oklahoma who has achieved these board certifications. She is also ranked as the #1 Provider for Acupuncture in the state.



Dr. Amalia Fantasia Bio

Dr. Amalia Fantasia Bio


Dr. Amalia Fantasia, PhD, is recognized widely as a leader in the field of health care, health care management, ambulatory health care and nutraceutical medicine. Acknowledged by chemists, bio-engineers, geneticists, physicians and health care administrators alike, Dr, Fantasia has pio- neered many of the preventive and integrative medical practices being standardized and inte- grated into traditional and primary health care today. The nutraceutical protocols and support treatments she has created in conjunction with physicians are well sought after on an international basis by patients and health care providers.


In 1996, she founded Cherry Hill Clinic, an ambulatory primary care practice serving the Southern New Jersey, Philadelphia and New York regions. As Clinic Director, Dr. Fantasia is not only responsible for the clinic’s founding and management, but was instrumental in developing its method of care processes and marketing, working with scientists, bio-chemists and Clinic Physi- cians in establishing entirely new health care modalities and standardizing primary and secondary health care treatment for the Clinic’s patients. As a health care management and bio-chemistry PhD, who has a particular focus in IV nutraceutical medicine as a preventive and support therapy for traditional health care, including cancer, opioid dependence, pre and post surgery, bariatrics and auto immune disorders,  Dr. Fantasia has developed a range of formulated proprietary IV nu- traceutical treatments that are becoming well known and sought after worldwide. Her clinical data from the same period has demonstrated the overwhelming success of Cherry Hill Clinic’s proto- cols and the modularization of the Clinic’s treatments and standard of care that are being sought after nationally by large-scale health care organizations and systems.


The author of several articles and studies in the field, Dr. Fantasia’s peer-reviewed works include: “The Value of Point of Care Testing in the Physician’s Office Setting,” in Advanced Labora- tory Medicine Magazine; “The Role of Nutraceutical Medicine in Preventing Cardiac Incident,” in Philadelphia Magazine;“The Assessment of Serum Markers as Related to Select Tumors,” published by Temple University Press; and “The Development of CPT Coding for Alternative and Preventive Medicine,” by City University of New York (CUNY) Press. Dr. Fantasia is also known widely for her many media and television appearances to discuss related health care topics, including appearances on CNBC,WBCB,WPEN and CNN, and she is also well known and respected as the host of her own weekly radio show serving Southern New Jersey and Philadelphia discussing topics related to health care with a focus on Nutraceutical and Preventive Medicine. In addition, Fantasia is invited to speak regularly by organizations on health care topics, including such well-known entities as the Pennsylva- nia Society for Clinical Laboratory Services, the Health Care Strategies Association, the Southern New Jersey Holistic Nurses Association, the American Nurses Association and the Philadelphia Busi- ness Women’s Network and Forum.


Prior to founding Cherry Hill Clinic, Dr. Fantasia, who has a PhD in Health Care Administra- tion from City University of New York, and a PhD in Chemistry, MBA in Health Care Finance and BS MT (AMT) in Chemistry from Temple University in Philadelphia, Pennsylvania, worked in various ca- pacities in the health care field gaining a diverse and wide range of experience in health care man- agement for medium and large scale hospital and related health care systems. From 1989 to 1996, she was Senior Consultant and Medical Laboratory Coding Specialist for Affiliated Health Manage- ment Associates in Chicago, Illinois, and from 1980 to 1985 the Outpatient Services Director for Broad Street Hospital Group in Philadelphia, where she also served as Hematology Supervisor be- ginning in 1974.  From 1969 to 1974, she was Senior Staff Technologist at Methodist Hospital in Philadelphia.


Dr. Fantasia is a member of several professional health care organizations including the American So- ciety for Clinical Pathology, the American Medical Technologist (AMT), the American Society for Clin- ical Lab Sciences (CLMA), the American College of Medical Practice Executives, the American College of Health Care Executives, and the American College for Advancements in Medicine. Dr. Fantasia also holds several Board certifications, including certifications from the Bupreneophine and Office-based Treatment for Opioid Dependence; the New Jersey Psychiatric Association; the International Acad- emy of Physiological Regulating Medicine; and the Association for Physiological Regulating Medicine in Pain Management and Aesthetic Medicine, among others. A native of Philadelphia, Dr. Fantasia lec- tures nationwide on subjects ranging from the semi-rapid detox of opioid dependence to the prac- tice and integration of preventive health care into existing health care systems and the successful use of IV Nutraceutical medicine to support traditional health care treatments and protocols.

Suicide, an Addictive Behavior

Suicide, an Addictive Behavior

Robert M. Lichtman, Ph.D., LMHC, CASAC, FAPA, MAC, CRS

Phone: 914-665-8622 or 914-960-9943


‘Daniel’ was intent on killing himself. He threatened his outpatient treating team and his family, that if he did not receive a prescription for Ativan, a highly addictive anti-anxiety drug, he was going to drink himself to death. In order to prevent this, his family took him to a psychiatric emergency room, where he was hospitalized as a danger to himself. Once again, he demanded that the ward psychiatrist give him the drug Ativan. As with most chemically dependent patients receiving efficacious treatment, the drug was not prescribed. He then persuaded his family into taking him home, promising that he would not harm himself. Unfortunately, they believed him and returned to the hospital, signing him out AMA (Against Medical Advice). Once home and out of his familys’ sight, he secured the anti-anxiety drug on the street, bought a liter of vodka, rented a room in a local motor inn and successfully committed suicide. The combination of Ativan and vodka proved to be quite lethal, and he knew it would be. Following a psychological “autopsy” and a root cause analysis, it was determined that Daniel “was going to do what he was going to do,” and the culpability was his own. I have often reflected on Daniel’s case and his drive to kill himself, thinking short of: locking him up and throwing away the key,” did we do everything clinically possible to prevent that suicide? That question haunts me to this very day. The concepts of free will and self-determination are challenging when someone takes their own life.

Running on Empty

Daniel was neither religious nor spiritual. Church and self-help programs held little value for him. The central activity in his life was to remain in the altered sense of consciousness produced by the psychoactive properties of an anti-anxiety drug. When the drug was not available, alcohol took its place, but that was not his drug of choice, Ativan was. Alcohol drove him into misery and made his hunger for Ativan worse. Daniel in an alcohol intoxicated state was literally hopeless, hapless and helpless. He was running on empty, unable to fill himself, and the alcohol was a poor second place substitute. It was the lure of Ativan that kept him going. He could not tolerate the protracted withdrawal enforced by the controlled environment of a hospital ward or a locked rehabilitation program. He had gone through countless detoxification and rehabilitation programs, both inpatient and outpatient.  His comfortable state was his addicted state and without the anti-anxiety drug in his system he was very uncomfortable. As with many substance dependent people, his tolerance increased exponentially to a point where he required four times the dosage indicated for someone with an anxiety disorder. Other medications were tried, all to no avail. They only made him tired and produced sleep. Once awake, the craving returned twofold. He could not live in his skin, the pain was too great. The addiction to the Ativan was now turning towards the drive towards death. He saw his life ending as the only way out of his misery and what was once an addition to the drug became an addiction to suicide.


When Ingestive Addictions Become Process Addictions

Specialists in addictive disorders usually separate behaviors that involve the administration of substances into one category and others like pathological gambling, shoplifting, exercising, the internet, and sexual compulsivity into another, hence the terms ingestive and process. They are not mutually exclusive, as people engage in both types of addictions and at times, simultaneously. I prefer to call the latter, “Addictions Without Substance,” although both have a payoff in the form of physiological, psychological and sociological reinforcement. Incidentally, I have seen a number of cases where the person’s life ended in an intentional suicide, either by design, as in Daniel’s case, or by moral deterioration, to a point where an “accident” takes the person’s life. When there is literally nothing more to live for other than seeing oneself being strangled and falling into a deeper abyss, suicide is no longer viewed as an option. The drive to die takes on all of the properties of addictive behavior, especially the obsessive and compulsive components. Suicide is not viewed as some clinicians say, “a permanent solution to an otherwise temporary problem,” it becomes the “solution” itself. The drive towards oblivion is all too powerful.

Note: The name of the case study in this article has been changed in order to maintain confidentiality.




Dr. Bob Lichtman, Ph.D., LMHC, CASAC, FAPA, MAC, CRS, is a clinical administrator at a psychiatric hospital and a professor at local colleges. He is a founding member and former president of the Addictions Division of the New York State Psychological Association and a specialist in the assessment and treatment of people who have co-occurring emotional and substance use disorders. Bob lives in the Fleetwood, a section of Mount Vernon, New York and maintains a private practice specializing in relationship counseling and addictive behaviors.


If you or anyone you know are in crisis, please know that you are not alone. You can reach out to the National Suicide Prevention Lifeline where skilled, trained counselors are available 24 hours a day, 7 days a week at 1-800-273-TALK (8255) or online at http://www.suicidepreventionlifeline.org/.


Complementary and Alternative Medicine for Older Adults with Depressive Symptoms:

Complementary and Alternative Medicine for Older Adults with Depressive Symptoms:

Analyzing Data from the 2012 National Health Interview Survey


Dr. Ryan Harrison, Psy.D.


University of the Rockies

School of Organizational Leadership

555 East Pikes Peak, Colorado Springs, CO  80903

United States

Phone: (909) 392-4392

Email: RHarrison@LivingAtHillcrest.org





This study explored how older adults with symptoms of depression relate to Complementary and Alternative Medicine (CAM) therapies.  Data from the 2012 National Health Interview Survey were analyzed to reveal the frequency of distinct CAM therapies’ use among depressed older adults, as well as subjective measurements of CAM therapy helpfulness in this population. Some CAM therapies such as natural supplements, chiropractic/osteopathic treatment, massage, yoga and acupuncture are utilized more commonly than others by older adults with symptoms of depression.  Similarly, some CAM therapies are also subjectively determined to be more helpful than others in managing symptoms of depression.  The major findings of this study suggested that some CAM therapies are used with greater frequency than others by older adults experiencing symptoms of depression. In addition, some CAM therapies are also perceived to be more helpful than others in terms of depression care and management.



older adult depression, complementary and alternative medicine, frequencies, National Health


Interview Survey


Although research has shown that depression is not an inevitable part of growing older, it does remain one of the most common mood disorders experienced by older adults (Centers for Disease Control and Prevention [CDC], 2012b; Geriatric Mental Health Foundation [GMHF], n.d.; National Institutes of Mental Health [NIMH], n.d.).  The literature is replete with data describing both risk factors for depression in the older adult population and the multiple adverse health effects of depression.  At the same time, diagnosing depression in the elderly population can be difficult for several reasons.  This has implications for treating this population, and research suggests that many depressed older adults go undiagnosed or under diagnosed and, therefore, untreated (Lakey et al., 2012; Wancata, Alexandrowicz, Marquart, Weiss, & Friedrich, 2006).

In general, standard treatment of depression for older adults places greater emphasis on prescription medications than on psychotherapeutic approaches (Wancata et al., 2006).  In some cases, the two are combined to significant effect (Blazer, 2003; NIMH, n.d.; Rojas-Fernandez & Mikhail, 2012).  Paradoxically, even when seemingly adequate treatment is available to depressed older adults, rates of compliance and adherence may be low.  Ivanova et al. (2011) found that physicians are more likely today than in earlier eras to prescribe antidepressants. Many older adults resist diagnosis and treatment and are willingly noncompliant with medical treatment.  Bosworth, Voils, Potter, and Steffens (2008) reported that as many as 20% to 80% of depressed older adults who are prescribed medications fail to adhere to their medication protocols one month later.  There may be additional reasons for medical noncompliance, including adverse side-effects caused by medications, the lack of a complete understanding of the benefits and risks associated with such treatment, cost concerns, alternate recommendations made by others, or preference for therapies that meet the patient’s more holistic needs (Bomar, 2013; Bosworth et al., 2008; Jin, Sklar, Oh, & Li, 2008; Tait et al., 2013).

Depression may itself predispose older adults toward poor medication compliance, including the under-use of medications or inappropriate discontinuation of the medication (Lutwak & Dill, 2012).  Problems with memory and cognition, poor vision or hearing, lack of social support, inadequate access to medication, economic burden, difficulty swallowing pills and the lack of dexterity or strength required to open drug containers or handle small pills may also predispose older adults to poor medical compliance (Jin et al., 2008).

However, non-adherence to medical care does not necessarily equate inaction on the part of older adults coping with depression.  Research suggests that a significant number turn toward CAM therapies (Astin, Pelletier, Ariane, & Haskell, 2000; Barnes, Bloom, & Nahin, 2008).  The suggested prevalence of CAM use among depressed older adults varies widely, although there is growing consensus in literature that it is steadily increasing.  In their study of CAM use in the elderly population, Astin et al. (2000) reported that 41% of a sample of older adults reported using CAM within the prior year.  Of these, 59% reported mood disorders such as depression while 80% reported improvement in their symptoms following CAM use (Astin et al., 2000).

A 2007 iteration of the NHIS, which included a CAM supplemental questionnaire, revealed growing use of CAM by older adults (Barnes et al., 2008).  Additional research utilizing the 2007 NHIS data found that older adults with chronic conditions including depression were more likely to use CAM than their healthier counterparts (Tait et al., 2013).  Certain health characteristics do contribute independently to CAM usage.  Three of these characteristics, strongly supported by research, are chronic conditions, comorbidity, and depression (Bishop & Lewith, 2008; Eisenberg et al., 1998; Keaton et al., 2009; Nahas & Sheikh, 2011; Park, 2013; Qureshi & Al-Bedah, 2013; Varteresian, Merrill, & Lavretsky, 2013).  Older adults often experience one or more of these predisposing factors suggesting there may be a significant numbers of older adults who are using CAM therapies specifically for treating depression and depressive symptoms.

Discerning precise statistics of older adult CAM usage is confounded, however, by low levels of CAM use disclosure. Numerous studies have found that as many as 38% – 60% of instances of CAM usage are not discussed with medical doctors or health care practitioners (Eisenberg et al., 1998; Nemer & McCaffrey, 2010; Willison, Williams, & Andrews, 2007).  The result is an inaccurate understanding of how many depressed older adults are using CAM therapies and how effective those CAM users find the therapies to be.  The data collected via the 2012 National Health Interview Survey (NHIS) and its CAM supplemental questionnaire can provide recent data that can be used to address these questions.


Study Data and Study Participants

The sample for this study consisted solely of participants in the 2012 NHIS Sample Adult survey and its CAM supplemental questionnaire.  Only data from respondents who indicated being 65 years of age or older were used.  The 2012 NHIS procedures were designed to collect data representative of the national population.  Accordingly, individuals aged 65 and older who were African American, Hispanic, or Asian had increased odds of being selected as the sample adult from each household (CDC, 2012a).

The NHIS is a cross-sectional household interview survey with sampling and interviewing occurring continuously throughout the year (CDC, 2012a).  According to the Centers for Disease Control and Prevention (CDC, 2012a), the NHIS sampling plan “follows a multistage area probability design” (para. 7) that is redesigned after every census.  For the 2012 NHIS, 428 primary sampling units (PSUs; consisting of counties, contiguous counties, or metropolitan areas) were drawn from all 50 states and the District of Columbia.  Within each PSU, 4 to 16 addresses were used.  For the adult sample of the 2012 NHIS, one civilian adult per family was randomly selected to self-report responses to survey questions, including those asked as part of the CAM supplement.  Because there were no identifiers associated with the NHIS data, and because the dataset was free to download and use in the public domain no official permission was required to utilize the data.

As illustrated in Table 1, of the 14,438 older adults sampled, 7,935 of those provided complete data, including gender.  Over 1,000 of the older adults indicated that they had been told by a health professional that they had depression.  Although 45% of the sample was missing gender-related data, 32% were coded as female and 22% as male.  The majority of the sample adults were Caucasian (44%), with African American being the second most prevalent reported ethnicity.  Table 1 indicates common demographics of this sample of older adults.


Table 1

Demographic Characteristics



N %























African American/Black

Indian (American), Alaska Native

Asian Indian



Other Asian

Primary race not releasable

Multiple race, no primary race selected





















Note. Data from 2012 National Health Interview Survey Sample Adult questionnaire and complementary and alternative medicine questionnaire.


Research Questions and Study Design

In this study, there were two research questions: (1) Which CAM therapies do depressed older adults use most commonly, as evidenced by a higher frequency of self-reported CAM use via the 2012 NHIS? and (2) Which CAM therapies do depressed older adults find most helpful for treating their mood disorder, as evidenced by a higher frequency of self-reported CAM therapies used for treating depression via the 2012 NHIS?

This correlational and quantitative study used frequencies of data from the 2012 NHIS to determine to which CAM therapies older adults with depressive symptoms utilized most commonly and which they found most helpful for managing their condition.  The NHIS CAM supplemental questionnaire invoked the term “CAM” to refer to 23 distinct therapies about which survey participants were asked directly.  These therapies included:  chiropractic/osteopathic medicine, massage, acupuncture, energy healing therapy, naturopathy, hypnosis, biofeedback, ayurveda, chelation therapy, craniosacral therapy, natural supplements, homeopathic treatment, meditation, mindfulness based therapy, guided imagery, progressive relaxation, yoga, tai chi, qi gong, the Feldenkrais method, the Alexander technique, Pilates, and Trager psychophysical integration.


            To answer the first of these research questions, regarding which CAM therapies depressed older adults used most commonly, frequencies were generated regarding the occurrence of specific CAM therapy use by older adults whose reported depressive symptoms were greater than zero.  Out of 7,889 older adults with depressive symptoms (indicated by responding in the affirmative to one or more of a range of NHIS items coded for symptoms of depression), the highest occurrence of CAM therapy use was natural supplements with 1,390 users.  This was followed by 612 participants who used chiropractic or osteopathic manipulation, 351 who used massage therapy, 294 who used yoga and 142 who used acupuncture.  These most commonly used CAM therapies are reflected in Table 2.  This dataset represented survey respondents who answered the questions about CAM therapy use in the affirmative.


Table 2

CAM Therapies Used Most Commonly by Depressed Older Adults


Type of CAM therapy

# of users % of users
Natural supplements 1,390 17.6
Chiropractic/osteopathic   612 7.8
Massage therapy   351 4.4
Yoga   294 3.7
Acupuncture   142 1.8


To answer the second research question, regarding which CAM therapies depressed older adults find most helpful for treating their condition, frequencies were calculated by filtering for depressive symptoms greater than zero and CAM therapy use greater than zero, based on three NHIS items that asked respondents which CAM therapies were their top three most important for addressing their health problem.

The top five CAM therapies reported by older adults with depressive symptoms as most helpful for addressing their health condition were chiropractic/osteopathic therapy (325), supplements (133), massage (117), acupuncture (65) and mind-body therapies (48).  Of those who reported using  therapies for managing their health condition, between 78.5% and 95.8% said that the therapy helped “some” or “a great deal.”  This is illustrated in Table 3.


Table 3

CAM Therapies Deemed Most Helpful by Depressed Older Adult CAM Users

Type of CAM therapy # who found therapy to help “some” or “a great deal” # who listed therapy as 1 of 3 top choices % who found the therapy to help “some” or “a great deal”
Chiropractic/osteopathic 287 325 88.3%
Natural supplements 109 133 82.0%
Massage therapy   99 117 84.6%
Acupuncture   51   65 78.5%
Mind-body medicine   46   48 95.8%



Both research questions, answered by descriptive statistical analysis, revealed similar findings.  More specifically, the five CAM therapies most commonly used by depressed older adults were found to be similar to those they found most helpful for treating or managing their health condition, with one exception. Mind-body therapies were felt to be more helpful than yoga and those findings may lay the groundwork for a number of additional research studies.

The first research question concerned the CAM therapies which older adults with depressive symptoms use most commonly.  As illustrated in Table 2, there were a combined 2,789 responses indicating use of one of five CAM therapies.  This number was generated by filtering the dataset to find data from older adults with depressive symptoms who also reported CAM therapy use (n = 7,889).  The most commonly used CAM therapy was found to be non-specified natural supplements, followed (in order) by chiropractic/osteopathic, massage, yoga and acupuncture.  Although additional CAM therapy usage was reported, the 142 positive responses related to acupuncture represented 1.8% of the sample; smaller results were deemed unnecessary for inclusion in the list of most common therapies.  Overall, this analysis revealed there is a general trend in the selection of CAM therapies by depressed older adults.

These findings provide current support for what previous research has uncovered.  A number of resources suggest that the five top CAM therapies resulting from an analysis of 2012 NHIS data are also among those that adults and older adults have used most commonly for many years (Astin et al., 2000; Lavretsky, 2009; National Center for Complementary and Alternative Medicine [NCCAM], 2013; Nemer & McCaffrey, 2010; Okoro, Zhao, Li, & Balluz, 2013; United States Department of Health and Human Services [USDHHS], 2011).  Indeed, research from the 2002 and 2007 iterations of the NHIS revealed similar results for the older adult population, suggesting a strong preference for natural supplements, acupuncture, chiropractic, massage and yoga (Barnes, Powell-Griner, McFann, & Nahin, 2004; NCCAM, 2013; Nemer & McCaffrey, 2010; Upchurch et al., 2007).

The answer to the second research question, regarding which CAM therapies depressed older adults found most helpful, was represented by Table 3.  The dataset suggested that the majority of CAM users found the therapies they used to be helpful either somewhat or a great deal.  This information was acquired by compiling data from older adults with depressive symptoms who used CAM and who answered a series of questions regarding their top three CAM therapies used to address their health problem.

The findings were similar to those resulting from the first research question.  The CAM therapies deemed most helpful also tended to be those that were most commonly used.  One exception was that yoga, which was a frequently utilized CAM therapy, was not one that was found to be among the most helpful.  Mind-body medicine appeared to take yoga’s place.  Further, mind-body medicine was found to have the highest degree of helpfulness, compared to other therapies, with a 95.8% response indicating helpfulness.  It should be noted, however, that this high degree of helpfulness was reported by only 48 individuals, representing fewer than 0.01% of the sample (n = 7,889).

The findings of this study were supportive of conclusions reached by earlier research.  For example, the connection between depressed individuals and the therapeutic application of mind-body practices is not new; a study by Meeks and Jeste (2007) found that depressed older adults in a geriatric psychiatric clinic reported greater use of mind-body CAM therapies than other subpopulations.  Earlier, Astin et al. (2000) conducted a survey of CAM therapy usage by 728 older adults in California, 80% reported receiving substantial benefit from the CAM therapies to which they turned.  Similarly, Cerino (2005) reported on a survey by the National Institutes of Health, which found that a majority (55%) of adults turned to CAM therapies for the perceived helpfulness of the therapies.

The present research study determined that, after mind-body therapies, chiropractic/ osteopathic (88.3%) and massage (84.6%) produced the next highest percentages indicating helpfulness, with natural supplements—the most commonly used CAM therapy—deemed helpful by 82.0% of respondents and acupuncture by 78.5%.  As mentioned earlier, however, it should be noted that this represented data provided by only 688 respondents, or 8.72% of survey respondents with depressive symptoms (n = 7,889) who used CAM over the prior 12 months.


There were several limitations in this study.  One includes the subjectivity of the NHIS.  Although the NHIS is a respected source of public health information, it’s nature as an interview schedule produces nonstandardized responses.  Many of the questions are subjective in nature such as the degree in which a CAM therapy was experienced as helpful.  While subjectivity is useful in qualitative research for measuring perspective and point of view, in quantitative research, it can have a confounding effect, making it a variable that should be controlled if possible (Drape, 2002; Mackellar, n.d.).  It should be noted that the NHIS includes subjective questions making some of the findings of this study unreliable.

In relation to the subjectivity of the NHIS, a second limitation of the current study is the necessary weight given to individual respondents’ personal understandings, beliefs and biases toward CAM therapies.  For example, there is little within the NHIS that helps a person understand what the different CAM therapies are or how they are used in practice.  As a result, respondents’ answers to items about CAM therapies could only be made from personal experiences.  If an individual had been exposed to CAM therapies by poorly prepared practitioners, the resulting answers to CAM-related items would have been unduly skewed.  This lack of standardization of knowledge and experience with CAM therapies may also contribute to unreliable findings.

The relative homogeneity of the study may represent another limitation.  Although some research suggests that depression is more common among minority groups than among white people (Dunlop, Song, Lyons, Manheim, & Chang, 2003), conflicting research suggests that the prevalence of major depressive disorder (MDD) may be higher in white people than in minority groups(Riolo, Nguyen, Greden, & King, 2005).  One common perspective, however, is that non-white, depressed older adults tend to seek treatment less readily than their white counterparts (Conner et al., 2010; USDHHS, 2011).  This may be reflected in the dataset resulting from the 2012 NHIS.  The majority of survey respondents were white (80%), suggesting that this study may not have captured significant data related to minority use of CAM therapies.

An additional limitation has to do with the design of the study.  This research project concerned depression, for which there are a number of standardized reliable and valid screens or interview schedules.  All of the data used for this study came from the NHIS.  Although the NHIS included the World Health Organization’s Composite International Diagnostic Interview Short Form (CIDI-SF) since 1999, as a survey, the NHIS is not considered a standalone depression scale (Egede, 2004; Kessler, 2007).  The items from the NHIS coded for a correlation to depression do relate to commonly known depressive symptoms (feeling sad, hopeless, worthless, etc.).  However, the data used for this study related to the incidence of depressive symptoms were subjective in nature.

The NHIS’s CAM supplemental questionnaire’s approach to the topic of natural supplements presented a confounding factor, as well.  Although it is well-known that there are many distinct natural supplements, as well as synergistic combinations of supplements that are advertised as helpful for mood stabilization (including ingredients such as St. John’s Wort, l-theanine, lemon balm, SAMe), the CAM supplemental questionnaire allowed respondents to select simply “natural supplements” as a distinct CAM therapy used within the prior year, without necessitating more specificity.  Because natural supplements, as a whole, comprise any number of vitamins, minerals, herbs, or other natural substances, its designation as a distinct CAM therapy can be considered a limitation insofar as it obfuscates more precise accounting of active compounds.  The degree of this limitation is quite clear when “natural supplements” was found to be the CAM therapy most commonly used and one of the five CAM therapies deemed most helpful by older adults with depressive symptoms. Not knowing which specific supplements were used by this population renders these particular findings somewhat negligible.

Finally, while data analysis revealed which CAM therapies depressed older adults used most commonly and which they found most helpful, these findings do not constitute a list of CAM therapies that have been rigorously tested for their utility in treating depression in older adults, and should be considered grounds for additional research.

Implications for Theory, Practice, and Future Research

            There are several implications for theory, practice and research resulting from this study.  First, the results of this study underscore what previous research has uncovered. Older adults living in the United States tend to turn toward some CAM therapies more readily than others.  Concurrently, there is some indication that the degree of scientific research into specific CAM therapies and their utility in treating depression is not a factor that drives older adults to CAM therapy use.  Barnes et al. (2008), for example, discovered that “there is no meaningful correlation between the number of published studies of a CAM therapy and its use by the American public” (p. 7).  The implication, supported by this current study, is that additional research needs to be conducted in order to discern precise reasons for the popularity of some CAM therapies over others in the older adult population.  Perhaps some reasons include the broader availability of some therapies over others, differences in cost, health insurance coverage, perceived variations in helpfulness, differences in the awareness of available CAM therapies, or internalized value judgments about specific CAM therapies.  Additional research is needed to discern whether these reasons, or others, bolster the popularity of some CAM therapies over others in this specific population.

Such research would support theories of CAM use by older adults that have already been suggested in the literature.  For example, a number of sources report a variety of reasons why older adults turn to CAM.  These include recommendations from health care providers, recommendations from friends, family, or coworkers, displeasure with conventional care approaches and the cost of conventional medicine. Other reasons include desire for general health improvement, need for pain management, desire for increased health autonomy, fear of side-effects from conventional medicine and desire for a more holistic approach to well-being (Astin et al., 2000; Bomar, 2013; Tait et al., 2013).  Thus, the results of this study support some previously reached conclusions while also giving emphasis to the need to further research the validity of proposed theories regarding the intersection of older adults’ use of CAM.

The implications of this research on potential changes in practice are modest.  In part, this is due to the nature of the study, which was not designed to elicit causal relationships.  However, given the large sample used in this study, the growing relevance of CAM therapies in the United States, and a changing perspective toward CAM therapies in the approaching older adult population (AHA, 2007; Cerino, 2005; Sioux, 2011; Varteresian et al., 2013), some suggestions can be made.  For example, although it is now common for therapists or other health care practitioners treating older adults to ask about CAM use to avoid negative treatment interactions and to produce a clear picture of overall care, professionals working with older adults with prior depression would have an additional reason for making such an inquiry.  Namely, knowing which CAM therapies depressed older adults find most helpful may be of use to practitioners who are less well-acquainted with CAM therapies in general.  Health care professionals who exhibit some expectancy that depressed older adults may be using CAM therapies may increase the likelihood within the clinical setting of CAM use disclosure, which has been difficult to determine (Eisenberg et al., 1998; Nemer & McCaffrey, 2010; Willison et al., 2007).

Further, clinicians can use the results of this study to inform their own research into the most common and helpful CAM therapies for their depressed patients.  This would have the dual benefit of familiarizing the health professionals with CAM therapies that might otherwise be considered inconsequential and also providing a research-based understanding of which sound integrative health care recommendations could be made.

Finally, should an older adult with depression ask for a recommendation of a CAM therapy, health care providers would be able to give a list of those therapies that other depressed older adults most commonly use as well as which therapies they find most helpful.  Even if the CAM therapies in question do not exert the kind of strong effects hoped for by either the practitioner or the patient, this would still represent an advance in practitioner-patient dialogue about the topic of CAM use.

As a result of this correlational study, several recommendations for further research can be made.  Studies could shed light on more precise relationships between each of the CAM therapies that depressed older adults use and find helpful and said therapies’ effectiveness.  Randomized, controlled, double-blind studies of distinct CAM therapies used for preventing recurrence of depressive symptoms or for treating depression in older adults have been conducted.  However, sample sizes tend to be small and such studies typically suffer from weaknesses in research design.  Correcting these limitations would constitute meaningful research.  Conducting a comparison analysis of the results of similarly scientifically strong studies could help determine the relative utility of some CAM therapies over others in relationship to older adult depression.

Additionally, a qualitative study regarding the reasons why depressed older adults self-select certain CAM therapies over others could yield important insights.  Such a study may reveal whether there are some CAM therapies that have correlating stigmas attached to them, discouraging their use and whether cultural familiarity with distinct CAM therapies increases the use of some therapies over others. The degree to which marketing campaigns influence CAM therapy selection and use may be a factor as well.  These findings would solidify a growing understanding of the complex relationship between CAM therapies and older adults’ health and wellness behaviors.



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doi:  10.1080/03601277.2012.734160

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Dr. Ryan Harrison, Psy.D., DAAIM, CWP, is the Director of Resident Life & Wellness at Hillcrest, a continuing care retirement community in Southern California.  After having practiced privately as a board certified health and wellness consultant for over ten years, Ryan completed his doctorate in Health & Wellness Psychology at the University of the Rockies, where he focused his research on the intersection of older adult health and well-being and Complementary and Alternative Medicine.  He currently leads a team of dedicated staff to optimize older adult health, fitness and wellness.


Who Has Helped Shape Your Therapeutic Style?

Who Has Helped Shape Your Therapeutic Style? 

By Erica Goodstone, Ph.D., LMHC, LMFT

A recent article in Counseling Today, an official publication of the American Counseling Association, began with the question:  “Who are the major influencers on today’s counseling professionals?”  I was fascinated by the variety of responses and the array of different professionals mentioned. Contemporary mentors were cited as well as influencers from much earlier times; these included both professional counselors and other thought leaders outside of counseling professions.  What struck me was the realization that each of us has taken our own unique path to becoming a qualified professional.  Each of us has learned different modalities and implemented the techniques in our own unique ways.  Each of us has been trained and mentored by different people.  And each of us has learned so much of what we know from people and situations outside of counseling or health professions.

When I think of who has influenced me, I begin with my junior high school English teacher who made me love the subject with her way of teaching through stories and drama and my college art teacher who took an assembly-ize audience into the heart and meaning of art history and artistic creation.  Then there was my dissertation advisor whose training in ego psychology led me to study and write about the long-term effects of mother-infant bonding upon adult love relationships.  In addition, there were all those consciousness-raising workshops I had taken in the 1970’s and 80’s and my spiritual awareness practices in yoga, meditation, and many different religious perspectives.  My own body aches from sports injuries as a fledgling professor of health and physical education, led me to receive and study many different body therapy methods, eventually learning the unique combination of talk with touch.  And my fascination with love, relationships and sexuality led me to undertake training with William Masters and Virginia Johnson in sex therapy. Finally, there were countless dedicated and skilled psychologists, social workers, counselors, coaches, psychiatrists and others who provided cutting edge training in the many different areas and aspects of counseling.

What influences a counselor or a healthcare practitioner to become skilled at their craft?  I believe there is no shortcut, no simple formula type training.  Psychotherapy and healthcare are both scientific and artistic endeavors.  We need specific knowledge and training in our niche areas of specialization.  We also need to do the inner work, to learn about the workings of our own mind, body and spirit.  And we need to practice, work with clients, continue our education to hone our skills, and integrate the many different types of learning into a cohesive approach to working with our clients.

Who and what has influenced you and shaped the way you work with your clients?
Please take a moment to think about this and share your thoughts with us.  Please feel free to email me your questions, comments, subjects you want to see covered, and topics which you, as an expert, would like to share here:  DrErica@DrEricaWellness.com.

If you are ready to collaborate and share on social media, join the Marketing Our Practices Facebook group at: https://Facebook.com/groups/MarketingOurPractices.

I look forward to working together with you to strengthen our professions in the coming months.


Erica Goodstone, Ph.D., LMHC, LMFT, LPC

Unexpected Surprises & Salt

Unexpected Surprises & Salt


Originally published August 11th, 2014 in Minerals & Vitamins, Eat for Health, Bon Appetit – Just Plain Good Food.

My life does not transport me into the metropolitan world much, however, every once in a while I journey to the hustle and bustle of the city. I was recently in Portland, Oregon, my state’s largest metropolitan area, and for a change I had time to explore. A large gap in my commitment schedule for the day allowed for an unexpected surprise.

I was walking along Mississippi Street, exploring small, artisan specialty shops and restaurants when I spied “The Meadow” (www.themeadow.net) where under the sign it read—Salt – Chocolate – Drink – Flowers — and my mouth begins to salivate whenever I think, read, write or talk about salt. I have craved salt for as long as I can remember and have gone to great lengths as a ranch kid to get my salt fix. I remember hot summer days sitting in an apple tree with a salt shaker in hand, eating green apples, tasting warm rhubarb stalks and eating carrots dipped in salt. So of course, across the street I went, to see if I had found my dream shop.

As I approached, the neatly arranged flowers, planter boxes with herbs and displays in the window caused a tickle of anticipation. As I stepped through the doors, I looked around hurriedly for a napkin because I was quickly turning into Pavlov’s dog. A vast variety of commercial salts greeted me, as well as a mountain of Himalayan salt cooking blocks of every imaginable size, and 12 foot floor to ceiling walls loaded with perfect glass jars of salt from around the world. Oh, and there were other non-important stuff like flowers, chocolate and wine too.

Mark Bitterman and his family have created a wonderful shop on this once industrial street of Portland. Mark is the author of Salted, A Manifesto on the World’s Most Essential Mineral, with Recipes. I am delighted to add this book to my collection and it is a must-own for holistic nutritionists, foodies, chefs, and thyroid & adrenal fatigue clients who know life simply doesn’t work correctly without salt.

In the Pacific Northwest, we have an ever-growing “Food” movement. This movement may have started with coffee and microbrews, but man cannot live on these beverages alone and they taste soooo much better when paired with the right foods and yes, that includes salt!

Salt has the unique ability to connect the world like no other mineral, ingredient or food. Men, like animals, have a need for salt to survive. It creates energy for the heart to beat correctly and for the brain, thyroid, liver and stomach to function properly. But the salt we think of is far from what was consumed around the world – Morton and the industrialized salt manufacturing of the USA is a far cry from the salt mines in Asia, Europe, and Brittany, France.

Throughout Europe, small communities know the name of the individual or family who raised the beef, potatoes, vegetables, bread, wine, cheese and salt they are eating. They have a connection, they have a community, family and shared cultural history. With this, comes the return of local or artisan salt. Natural salt is available in a huge array of colors, flavors and crystal characteristics. Some are perfectly suited for confectionery masterpieces like Fleur de Sel Caramels. These salted caramels originated in Brittany, France, due to the availability of the artisan-made salts in the region.

In the United States, we generally have three varieties of salt, much of which are the same way. Mark Bitterman so aptly states in his book; “Some things do not belong in our food supply. Industrial salts like cheap sea salt, kosher salt, and table salt are products that few people want in their kitchens if they understand and face up to how they are made.”

Perhaps our decline in home cooking and our dependence on commercial foods has corrupted our sense of taste. While I am no expert, I know I can clearly taste the differences in salts and I do appreciate the value of real salt for our health. If we are enjoying the fresh abundance of produce from community supported agriculture and farmers markets, we already understand how much better local, fresh foods taste over limp, lifeless store versions. So why wouldn’t we want to use natural salts to make those flavors pop and zing even more?

I’m off to buy a salt block to try some of grilled steak recipes out …. now we are talking summer!

To Your Good Health, Real Foods.