Trauma and Sleep
Article written by: Macie Stead MS, LMHC
Sleep is an often-underappreciated event by those who can do it well. Those who struggle with sleep problems- waking up too early, difficulties falling asleep, or intermittent sleep during the night- understand all too well how devastating lack of quality sleep can be. Now, consider someone who has experienced a traumatic event, their brain and body is out of sync with difficulties finding a cohesive rhythm. Imagine a dance partner who continues to step on your toes and has serious problems keeping up with the beat. Sleep is all about rhythm, the circadian rhythm to be exact.
Circadian rhythm is the biological process of physical mental, and behavioral changes that follow a roughly 24-hour cycle that responds to light and darkness (National Institute of General Medical Sciences (NIGMS), 2012). The circadian rhythm can impact sleep-wake cycles, hormone release, and body temperature; a malfunctioning rhythm can develop into sleep disorders and have been associated with obesity, depression, bipolar disorder, and seasonal affective disorder (NIGMS, 2012).
According to the National Sleep Foundation (NSF) (2017) someone who has experienced trauma gets an increased boost of epinephrine and adrenaline which can negatively impact a normal sleep cycle. According to the National Sleep Foundation (NSF) (2017) common sleep problems after trauma can include: flashbacks, frightening thoughts, high levels of alertness, fear of nighttime and darkness, and nightmares. Sometimes people will turn to drugs or alcohol to numb themselves mentally and physically; however, drugs and alcohol are proven to impact the healing process and make sleep problems worse.
What are some options for sleep problems if you have experienced a traumatic event?
Sleep tips and information were created by Witness Justice, in partnership with the National Sleep Foundation, Dr. Barry Krakow of The Sleep and Human Health Institute and Dr. Gregory Belenky of the physician and a leading sleep researcher of the Walter Reed Institute of Research.
Questions Raised by Masters Mental Health Counseling Students
1.Why is APA formatting necessary? “I’m not an English Student.”
The American Psychological Association (APA) developed APA formatting to create a standardized format for the social and behavioral sciences. APA format serves multiple functions that improve writing quality and gives credit to authors. The strict formatting in APA provides a structured guideline in how papers should look. Students can then know where certain information will be within any given journal article.
The use of references shows deliberate, critical-thinking, and linking concepts with the professional field. Giving credit to an author through citations and references demonstrates respect and helps to avoid plagiarism in writing. Citations also help other readers find the sources of information in journal articles.
2. After all this work in school, am I employable?
Most students want employment after their Master’s program, but few fully understand the steps involved. A career in mental health counseling or social work is a multi-step endeavor. Once a student completes their Master’s program, there are typically post-graduate hours to get licensed. Why get licensed? Well, being licensed is the legal requirement in all 50 states that provide mental health counseling or social work to clients. Licensed counselors and social workers have met clinical postgraduate hour requirements and supervision hours. There is typically a licensing exam, such as the National Counselor Exam, that is also required before an application can be submitted. Different states have different requirements. Check with your state to ensure you know all the requirements for licensure.
The good news is that some agencies can hire post-graduate interns under an agency-affiliated license. The company covers the student under their professional liability insurance and agency license. Pay, however, may be at a lower level depending on the agency until fully licensed. Agencies want clinicians to be fully licensed so they can bill insurance companies for services. Individuals seeking licensure can hire an outside supervisor for postgraduate supervision hours, and the agency may also require supervision on-site.
Once you have your clinical license, many positions can become available depending on your Master’s program focus area. Mental health counseling in agency-settings, case management (in some states this can be done with a BA), school counseling, and private practice (this is a big leap right out of a Master’s program and can be isolating). Specialty areas such as domestic violence, substance abuse, and sexual offenders (depending on state and agency requirements) may require additional training.
3. What are good associations to join as a student?
A solid organization to start with is the American Counseling Association (ACA). As an active member, ACA members utilize the code of ethics, which are available online with other helpful resources. ACA also has networking opportunities, national conferences, and free CEU opportunities. If you are an ACA member, you can also get a discount on HPSO liability insurance. ACA also holds specialty divisions and local chapters.
ACA Website: https://www.counseling.org/
Association for Adult Development and Aging (AADA)
Chartered in 1986, AADA serves as a focal point for information sharing, professional development, and advocacy related to adult development and aging issues; addresses counseling concerns across the lifespan.
Association for Assessment and Research in Counseling (AARC)
Originally the Association for Measurement and Evaluation in Guidance, AARC was chartered in 1965. The purpose of AARC is to promote the effective use of assessment in the counseling profession.
Association for Child and Adolescent Counseling (ACAC)
Association for Child and Adolescent Counseling aims to focus on the training needs of counselors who work with children and adolescents, while also providing professional support to those counselors, whether they are school counselors, play therapists, or counselor educators.
Association for Creativity in Counseling (ACC)
The Association for Creativity in Counseling (ACC) is a forum for counselors, counselor educators, creative arts therapists and counselors in training to explore unique and diverse approaches to counseling. ACC’s goal is to promote greater awareness, advocacy, and understanding of diverse and creative approaches to counseling.
American College Counseling Association (ACCA)
ACCA is one of the newest divisions of the American Counseling Association. Chartered in 1991, the focus of ACCA is to foster student development in colleges, universities, and community colleges.
Association for Counselor Education and Supervision (ACES)
Originally the National Association of Guidance and Counselor Trainers, ACES was a founding association of ACA in 1952. ACES emphasizes the need for quality education and supervision of counselors for all work settings.
The Association for Humanistic Counseling (AHC)
AHC, formerly C-AHEAD, a founding association of ACA in 1952, provides a forum for the exchange of information about humanistically-oriented counseling practices and promotes changes that reflect the growing body of knowledge about humanistic principles applied to human development and potential.
Association for Lesbian, Gay, Bisexual and Transgender Issues in Counseling (ALGBTIC)
Educates counselors to the unique needs of client identity development; and a non-threatening counseling environment by aiding in the reduction of stereotypical thinking and homoprejudice.
Association for Multicultural Counseling and Development (AMCD)
Originally the Association of Non-White Concerns in Personnel and Guidance, AMCD was chartered in 1972. AMCD strives to improve cultural, ethnic and racial empathy and understanding by programs to advance and sustain personal growth.
American Mental Health Counselors Association (AMHCA)
Chartered in 1978, AMHCA represents mental health counselors, advocating for client-access to quality services within the health care industry.
American Rehabilitation Counseling Association (ARCA)
ARCA is an organization of rehabilitation counseling practitioners, educators, and students who are concerned with enhancing the development of people with disabilities throughout their life span and in promoting excellence in the rehabilitation counseling profession’s practice, research, consultation, and professional development.
American School Counselor Association (ASCA)
Chartered in 1953, ASCA promotes school counseling professionals and interest in activities that affect the personal, educational, and career development of students. ASCA members also work with parents, educators, and community members to provide a positive learning environment.
Association for Spiritual, Ethical, and Religious Values in Counseling (ASERVIC)
Originally the National Catholic Guidance Conference, ASERVIC was chartered in 1974. ASERVIC is devoted to professionals who believe that spiritual, ethical, religious, and other human values are essential to the full development of the person and to the discipline of counseling.
Association for Specialists in Group Work (ASGW)
Chartered in 1973, ASGW provides professional leadership in the field of group work, establishes standards for professional training, and supports research and the dissemination of knowledge.
Counselors for Social Justice (CSJ)
CSJ is a community of counselors, counselor educators, graduate students, and school and community leaders who seek equity and an end to oppression and injustice affecting clients, students, counselors, families, communities, schools, workplaces, governments, and other social and institutional systems.
International Association of Addictions and Offender Counselors (IAAOC)
Originally the Public Offender Counselor Association, IAAOC was chartered in 1972. Members of IAAOC advocate the development of effective counseling and rehabilitation programs for people with substance abuse problems, other addictions, and adult and/or juvenile public offenders.
International Association of Marriage and Family Counselors (IAMFC)
Chartered in 1989, IAMFC members help develop healthy family systems through prevention, education, and therapy.
Military and Government Counseling Association (MGCA) formerly ACEG
Originally the Military Educators and Counselors Association, MGCA was chartered in 1984. MGCA is dedicated to counseling clients and their families in local, state, and federal government or in military-related agencies.
National Career Development Association (NCDA)
Originally the National Vocational Guidance Association, NCDA was one of the founding associations of ACA in 1952. NCDA provides professional development, connection, publications, standards, and advocacy to career development professionals who inspire and empower individuals to achieve their career and life goals.
National Employment Counseling Association (NECA)
NECA was originally the National Employment Counselors Association and was chartered in 1966. The commitment of NECA is to offer professional leadership to people who counsel in employment and/or career development settings.
According to Vandegrift and Mutusitz (2011) Columbia Records, founded in 1888, is a major thriving music industry that has helped establish famous musicians, recording instruments, and is a digital music pioneer. The long-standing career of Columbia Records has increased employment within its company, as well as rocketing performing artist’s careers. The path-goal leadership approach has been an essential component to Columbia Records success. Columbia Records utilizes expectations, support systems, barrier removal, and teamwork (Vandegrift & Mutusitz, 2011).
Participative Leadership Behavior
At the root of path-goal theory is another theory called expectancy theory. According to Northouse (2016), expectancy theory identifies the needs required by individual members to motivate them as a leader. Towards the end of the nineteenth century, Columbia Records was forced to consider more efficient ways to produce quality music (Vandegrift & Mutusitz, 2011). Other musical agencies did not want to collaborate with Columbia because their cost for quality was high. Columbia Records took a unique approach and asked for the participation of Columbia Records employees. According to Vandegrift and Mutusitz (2011) managers would frequently ask employees for advice; which directly impacted the efficiency and lowered cost of products. The value Columbia placed in employees helped them to feel more invested in the company. Columbia Records felt the artist were assets with essential contributions (Vandegrift & Mutusitz, 2011). According to Northouse (2016), a participative leader gathers ideas from group members and incorporates them into the decision-making process. Gathering information from different levels of employees helped motivate newer employees.
Supportive and Directive Leadership
Path-Goal theory has defined the way Columbia Records operates within the music industry. Even as some musical industries have taken over a 16% loss in sales due to digital music downloads, Columbia has seen more records (digitally and in stores) sold (Vandegrift & Mutusitz, 2011). The leadership approach increased positive outcomes and overcame serious obstacles. According to Vandegrift and Mutusitz (2011), The leader should clarify expectations and help navigate barriers with a directive approach to leadership. A directive approach contributed to involve all members of Columbia Records to set clear expectations and goals. Another benefit of the direction style was the care provided for employee concerns. Considerations for employee well-being helped establish a friendly and safe work environment at Columbia Records (Vandegrift & Mutusitz, 2011).
According to Northouse (2016), path-goal leadership relies on the motivation of the leader to influence successful outcomes from the followers. Path-goal theory postulates that success is not necessarily the responsibility of the members. To be motivated to achieve, individuals must see a leader who emanates behaviors necessary to reach the goal. Motivation to achieve a target relies on both on the ability to demonstrate passion, support, and clear guidance around obstacles (Vandegrift & Mutusitz, 2011).
One potential limitation noted in the article was cultural sensitivity. According to Vandegrift and Mutusitz (2011), more research needs to be conducted on the effectiveness of the path-goal theory of diverse cultures. The leadership approach of being collaborative may not be a good fit for some cultures who are more authoritative.
Northouse, P. G. (2016). Leadership: Theory and practice. Thousand Oaks, CA: Sage Publications.
Vandegrift, R., & Matusitz, J. (2011). Path-goal theory: A successful Columbia Records story. Journal of Human Behavior in the Social Environment, 21(4), 350-362. doi:10.1080/10911359.2011.555651
Does my Counseling Experience Qualify me to be a Supervisor?
Experience is necessary, but it is not the whole enchilada.
Supervision and counseling are two professional roles that often intertwined, and sometimes confused. Supervision is the act of guidance and gatekeeping for new professionals in the field of counseling (Bernard & Goodyear, 2014). Supervisors have counseling experience and typically have their own style of supervision to help communicate skills and problem solving. Counselors can become supervisors, after experience and some additional training. Supervision can be used with new counselors and even seasoned counselors trying to gain insight or guidance on a difficult case or on a topic that is unfamiliar. Comparisons of the counselor and supervision roles are important to explore how to best enhance each role.
Counseling is the direct and indirect work with client on therapeutic goals. Supervision is direct and indirect work with a counselor to help enhance professional identity and clinical skill. Supervision is a process every mental health student encounters as they work to complete course requirements for a Masters degree and PhD. Aside from just being a requirement for coursework, supervision provides as guidance and as a gatekeeper in the field. Many state licensures allow for a counselor to become a supervisor after a certain number of years of experience counseling. Although experience does help ensure the potential supervisor has clinical skills and knowledge, it may not specifically focus on supervision skills that may be necessary to be an effective and ethical supervisor (Parcover & Swanson, 2013). There are similarities and differences between counseling and supervision that can help better identify the focus of the supervisory role.
According to Bernard and Goodyear (2014) supervisors work to develop engagement between professionals, comfort with approaching uncertainty and ambiguity in the field, and formation of professional identity. Supervision is a balance between applying clinical knowledge to case studies, relationship building with peers in the field, and guidance to new professionals. The role of a supervisor is to develop a close professional relationship with the supervisee that helps promote knowledge and skill, while still keeping the safety of the community as a priority (Bernard & Goodyear, 2014).
One skill that is unique between counseling and supervision is the role of collaboration. A counselor may have to tackle a clinical problem independently. Supervision can utilize collaboration to build upon strengths and adjust to ambiguity with another professional in the field who has a different perspective (Rousmaniere & Ellis, 2013). The collaboration in the field can help to solve problems with more ease, ultimately providing higher quality care for clients. The supervisor acts in a unique role that mirrors a mentor with vested interested in client well being and ethical decision making. Another conclusion from this comparison is that new professionals really need guidance when troubleshooting client problems. Isolation that can be felt in the field can be dangerous to client welfare. Instead of trial and error, or misinformation, a student can ask for supervision from someone with the counseling experience.
Supervision can occur in different forms, creating ease for supervisors who have multiple supervisees. The traditional 1:1 supervision style provides attention to a supervisee to focus on troubleshooting, monitoring, and modeling. According to Milne and Oliver (2000) the bias of preferring individual supervision might just be from comfort and fear of trying new formats. A limitation of the individual therapy approach is that with the increase of new professionals to the field, it can be difficult to keep up with the need of the field only supervising one supervisee at a time (Milne & Oliver, 2000). The triadic format of supervision is where there are two supervisees that work cooperatively and collaboratively with the supervisor. The benefits of the triadic supervision approach are that each supervisee can still have an intimate role with the supervisor, but more can be accomplished in one session (Milne & Oliver, 2000). The new professionals can work together to solve problems and may be able to problem solve cooperatively. The reduction in isolation can also improve the supervisee’s collaboration skills and adherence to paperwork and ethical guidelines. A downside to the triadic approach is that it might be difficult to approach professional identity concerns that are impacting the counseling session. For example, if a counselor is demonstrating bias towards another culture in session, it has to be addressed, but finding an appropriate time might be more difficult. The group format allows for many, usually three or more, to learn form each other while also learning from the supervisor. The group format allows for group learning, enhanced efficiency, and healthy challenges from peer to peer interactions (Milne & Oliver, 2000). One limitation of the group experience is that the supervisee may not feel they get enough time to the supervisor to talk about challenges without other group members present. Although there is some limitations when working with a group supervision format, it does appear to promote collaboration between diverse professionals that can help to identify themes and solutions.
Bernard, J. M., & Goodyear, R. K. (2014). Fundamentals of clinical supervision (5th ed.). Upper Saddle River, NJ: Pearson Education, Inc.
Milne, D., & Oliver, V. (2000). Flexible formats of clinical supervision: Description, evaluation and implementation. Journal Of Mental Health, 9(3), 291-304. doi:10.1080/09638230050073455
Parcover, J. A., & Swanson, J. L. (2013). Career counselor training and supervision: Role of the supervisory working alliance. Journal Of Employment Counseling, 50(4), 166-178. doi:10.1002/j.2161-1920.2013.00035.x]
Rousmaniere, T. G., & Ellis, M. V. (2013). Developing the construct and measure of collaborative clinical supervision: The supervisee’s perspective. Training And Education In Professional Psychology, 7(4), 300-308. doi:10.1037/a0033796
Physical effects of exercise
Physical activity is defined as energy that is burned from the body doing any numerous amount activities (Marks, Murray & Evans, 2011). Physical fitness allows the body systems to move more naturally and helps organs, muscles, and skeletal systems work at their best. Staying active and exercising is important for meeting biological drives and energy needs in the body. According to Warburton (2006), regular physical activity, burning around 2,000 calories per week, was associated with an increase in life expectancy of 1-2 years by the age of 80 years-old. Those who are disabled or physically fragile saw benefits even when completing lower amounts of exercise that were consistent over time. Working to meet weekly energy expenditure goals could help individuals improve their current physical health and also offset possible future disabilities or illnesses. With TV, video games, fast food, and social networking websites and Apps a reduction in physical activity can impact overall health. Only one-third of American youth receive the appropriate amount of exercise (Plante, Gores, Brecht, Carrow, Imbs, & Willemsen, 2007). A larger majority of people in the US are staying more sedentary in their daily lives and their intake of fatty/oily foods is increasing. Half of American adults do not get their recommended amount of exercise and about one-fourth of this population does not exercise at all (Plante et. al, 2007). When people sit and remain inactive, taking in more energy than they expend, they are putting themselves at an increased risk for both short-term and long-term health dangers.
Imbalance in exercise and food intake can create health problems such as obesity, cardiovascular disease, colon cancer, type 2 diabetes, stroke and breast cancer (Marks, Murray & Evans, 2011). Cardiovascular disease is a growing problem in the US, but exercise has demonstrated a positive impact in creating healthier lifestyles. Staying physically active can be related with a 50% or higher risk reduction for cardiovascular disease (Warburton, 2006). Individuals who exercise can live longer, have healthier hearts and circulatory systems. The research that has been conducted demonstrates that obesity rates decline with exercise and even a small amount of activity change can drastically impact a persons overall health. Comparatively, a physically inactive, middle-aged woman (less than 1 hour per week), experienced a 52% increase in overall mortality, a doubling of cardio-vascular related mortality and a 29% increase cancer-related mortality compared with physically active women (Warburton, 2006). Different types of exercise have been shown to improve certain health risk potentials. Using weight-bearing exercises can help improve osteoporosis. Aerobic and resistance workouts can help improve risk for type II diabetes. A consistent, moderate, workout plan can help reduce the risk for all cancer types but particularly, breast and colon cancers.
Psychological effects of exercise
The amount of beneficial impacts the body feels from exercise also translates to psychological wellness. Exercise ranging from 5-30 minutes has been found linked with psychological well-being and positive affective responses (Hogan, Maata & Carstensen, 2013). Endorphins and other “feel good” chemicals get released in the brain allowing a person to feel elated after exercise. Physical activity can aid in reducing rates of depression, anxiety, and stress-related disorders. Feeling good after exercise can help individuals feel motivated to continue being active or do things they find pleasure in. According to Mata, Hogan, Joormann, Waugh and Gotlib (2013), exercise has been shown to improve positive affect in individuals with major depression when compared with individuals who have more sedentary lives. Individuals suffering from major depression have a difficult time finding pleasure in activities and continuing with hobbies they use to enjoy. Exercise can break the cycle of depression by allowing the natural endorphins to help them “feel good” while aiding them in moving out of their depressive cycle. According to Plante et. al (2007), many of the benefits of mood improvement are linked with socialization during physical activity. Individuals who join groups, classes or weight loss programs can help improve affect, overall physical health and feelings of “belonging”.
Gender and the benefits of exercise
Men and women have different impacts on their physical and psychological health from exercise. The physical effects of exercise is beneficial for both men and women but how bodies process this energy may be different. Women commonly wonder why their husband or boyfriend can eat just as much as them or more but not gain weight. Men have higher muscle mass that burns intake quicker and more effectively than women. Due to gender differences in body composition between fat and muscle, women often have to search and find weight loss programs or groups to meet their desired goals. Many of these visually slim goals have high standards set by society and media. Some women, and men as well, struggle with high expectations and have a hard time finding a supportive environment to exercise. According to Plante et. al (2007), women get the most psychological benefits from exercise that is conducted in social groups, such as gyms instead of at home in isolated settings. Men may also receive similar benefits of social exercise but they have less of an initial to push to improve their health in the first place. Men receive less educational information about health and exercise from practitioners and other health providers (Hatchell, Bassett-Gunter, Clarke, Kimura & Latimer-Cheung, 2013). Men may not exercise as frequently as women, due to a lack of information, about the need for certain amounts of exercise a week/day.
Plante, T. G., Gores, C., Brecht, C., Carrow, J., Imbs, A., & Willemsen, E. (2007). Does exercise environment enhance the psychological benefits of exercise for women?. International Journal Of Stress Management, 14(1), 88-98. doi:10.1037/1072-5245.14.1.88
Hatchell, A. C., Bassett-Gunter, R. L., Clarke, M., Kimura, S., & Latimer-Cheung, A. E. (2013). Messages for men: The efficacy of EPPM-based messages targeting men’s physical activity. Health Psychology, 32(1), 24-32. doi:10.1037/a0030108
Mata, J., Hogan, C. L., Joormann, J., Waugh, C. E., & Gotlib, I. H. (2013). Acute exercise attenuates negative affect following repeated sad mood inductions in persons who have recovered from depression. Journal Of Abnormal Psychology, 122(1), 45-50. doi:10.1037/a0029881
Marks, D. F., Murray, M., Evans, B., Esttacio, E. V. (2011). Health psychology: Theory, research, and practice, 3rd ed.). London: Sage.
Warburton, D. E. (2006). Health Benefits Of Physical Activity: The Evidence. Canadian Medical Association Journal, 174(6), 801-809.
What do clinicians diagnose with?
The Diagnostic and Statistical Manual of Mental Disorders (DSM) was originally released by the American Psychiatric Association, when it changed its name in 1921. The DSM-IV-TR and the new DSM 5 are the currently used editions. The DSM 5 is now active, released in 2013, but some agencies, including my own will not be transitioning until later 2015. The DSM is a very large book that uses number coding and criteria to help clinicians and clients classify mental health disorders. The DSM is purely for diagnosing purposes and is not a guide for treatment, nor does it specify guidance for ethical decision making in practice.
Differences between DSM-IV-TR and DSM 5-
1) Change from roman numerals to standard numbers in an attempt to make the DSM 5 more accessible and easy to understand internationally and not just in the US.
2) The last DSM-IV was published in 1992, and had yet to be updated with current terminology, so a revised edition was published but a full DSM rewrite was not started until 1999. Very important to stay current!
3)The DSM-IV-TR was written from a medical model, by medical and psychiatric professionals, and did not include counseling professionals feedback. The DSM 5 was written from a variety of outlooks with professionals from many fields contributing to the contents.
What is a diagnosis?
The numerical diagnosis code, for example 300., is given for ease of categorizing, and is not as intimidating as it appears. For example, the diagnosis that associates with the code 300.00 is Anxiety Disorder NOS. NOS meaning=not otherwise specified (it doesn’t fit the criteria for a more specific anxiety disorder). Addition .XX numbers can be added as specifers for things like mild, moderate, and severe. Additional specifiers can be added for acute or chronic, these depend on the specific diagnosis.
So is it good or bad?
Simple answer…..it depends.
A diagnosis is often the most associated stigma within mental health counseling. Over-diagnosing, poor diagnostics, and lack of client psychoeducation leads to stigma in the field and anxiety from both clients and clinicians. A diagnosis is given to help classify and standardize the assignment of clinical treatment. The diagnosis can be helpful to ensure that standards and criteria are being followed in order to diagnose accurately. Tricky part is that diagnosis, unfortunately, is subjective so what applies for one client and one clinician can be different from one therapy setting to the next. For example, a substance abuse clinic will most like place the chemical dependency or abuse diagnosis as the primary, while a mental health agency might place it as a secondary diagnosis, or may fail to address it at all. Subjectivity can be a good thing however, for those who understand their clients well and may know more details than the criteria can cover itself.
What were your experiences with being assigned a diagnosis?
My professional opinion?
Although I feel I just started to understand the last DSM coding structure, I believe the new DSM 5 is more suitable for working with people in a counseling vs. a clinical setting. The DSM 5 is more user friendly and takes into account the social and environmental factors that influence behaviors. I view diagnosing as a requirement for insurance that is not necessarily needed to understand symptoms, or have effective treatment. It is helpful to be able to collaborate with others in the field, have a specialty area, and understand similarities between clients. I do however, find it is equally important to value diversity, individuality, and having a fresh perspective for each client without get “swept away” trying to make someone fit into a diagnosis category.
People are people. period. It is important to be present and be with the client, not checking boxes in your mind.
Some Additional Information
I included a link to a PDF outline with some of the basic changes made to the new DSM, and a link to more information on the detailed history of the DSM, hope you find it helpful. Any questions please feel free to ask.