Self-Injury - Mythbusting

The orange Self-Injury Awareness ribbon

As I stated in my previous article, Non-Suicidal Self-Injury is one of the most mythologized, misunderstood, and ignored mental health issues we face.  This second article in the series will hopefully dispel some of those myths.

Most of the statistics quoted in this article were gathered through a longitudinal study performed in British Columbia from 2003 to 2005 by Mary K. Nixon, MD, FRCPC, Department of Psychiatry, University of British Columbia, Division of Medical Sciences, University of Victoria, Mikael Jansson Ph.D. Department of Sociology, University of Victoria, Paula Cloutier MA, Mental Health Research Unit, Children’s Hospital of Ontario

THE MYTHS;

“Self-injury is a failed suicide attempt”

Though people who self-injure should be screened for suicidal ideation, the act of self-injury in itself is typically not intended as a means of suicide.  For most, it is a coping method used to survive, not to end life.  For many – (50% according to Nixon, et al, 2005) - self-injury drives away sometimes overwhelming emotions and urges to complete suicide to end unbearable emotional distress.  So for them, self-injury may be the only thing keeping them alive.

It is true that there are higher completed suicides amongst those with a prolonged history of self-injury, but to understand the relationship between self-injury and suicide, one must look at the related emotions behind motive; Many people who attempt or complete suicide do not want to die, they want the emotional torment to end and killing themselves seems like the only way to do it.  The shame and guilt some feel after an episode of self-injury can also result in a person wondering if they should live or die.  Plus self-injury can lead to accidental death

“People self-harm to fit in or be cool”

The most recent statistics indicate that about 17% of adolescents between the ages of 12 and 18, will self-injure for a period of 21 months.  What is very revealing about the longitudinal study in BC was that many of the young people surveyed lived in isolated communities and 72% said they came up with the idea to self-injure on their own.  Therefore, self-injury amongst the adolescent population is not a trend or fad.

“It’s only a teenage thing - they will grow out of it”

In the same BC study cited above, 42% did not “grow out of it”, and continued to self-injure into adulthood.

“People who self-harm could stop if they wanted to”

Some can and do stop (58%), but self-injury can become addictive.  There are many who argue that self-injury is a process addiction, that the ritualistic elements of the behaviour become habitual.  There are others [this writer included] that have seen enough evidence to believe that self-injury can become a biochemical addiction.  The act of self-injury – of causing a wound to one’s body – triggers the same response as though the person had been injured accidentally.  When injured, endorphins are released by our pituitary gland and hypothalamus.  Endorphins are endogenous opioid peptides that function as neurotransmitters and are often referred to as the body’s "natural heroin".  Just like heroin, one can become addicted to endorphins. [Note: a future article in this series will examine self-injury addiction in more detail]

“People who self-injure have been abused”

Not necessarily; Though the BC survey indicated that 85% of those who self-injured reported some form of past trauma – abuse, neglect, unresolved grief & loss, bullying at school or in the community - there are diverse triggers that can lead to self-injury and many people who do it cannot always say what brings it on.  For many, the act of self-injury is a way to cope, to release tension, to relieve stress or pressure.

“Self-injury is when you cut yourself”

Cutting is only one of many forms of self-injury and, although it is most common, there are many others, including; scratching, burning, imbedding, hair pulling, hitting, biting, head-banging, ingesting drugs or a non-ingestible substance or item, ingesting alcohol  or illicit narcotics to excess, or interfering with wound healing.

“People self-injure to get attention”

Young people self-injure in response to emotional distress, and most hide it from friends and family and go to great lengths to cover their injuries and scars.  But if someone was going to the extreme of taking a razor blade and cutting their flesh to get our attention, don’t you think we should give it to them?

“If you self-injure you have Borderline Personality Disorder (BPD)”

Self-injury can be a symptom of BPD but only as part of a complex set of other criteria.  This false assumption arose due to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) criteria for a BPD diagnosis including self-injury as part of repeated suicidal behaviour.

“They will stop if their tools are taken away”

By taking away the familiar tools from someone who self-injures, we are - in most cases - forcing them to use unfamiliar tools when they need to find relief and they then risk greater injury or possible death.  Many in the world-wide self-injury peer support community have even found makeshift tools in psychiatric hospitals that pride themselves on being “safe” facilities; staples, paperclips, the threads on a faucet, broken glass, broken plastic, even the foil lid from a yoghurt container have all been used to fashion tools to self-injure right under the noses of hospital staff.  Taking away a person's tools will not "cure" them; Treating the underlying cause of self-injury is best accomplished under the care of a qualified and experienced therapist who understands self-injury.

“Self-mutilation …”

The term “self-mutilation” is not synonymous with self-injury.  Many who self-injure take great offence and are hurt by the term because it speaks to motive.  Most people who self-injure don’t do so to create scars or disfigure their body, they do so to find relief from overwhelming emotions or tension.  The term “self-mutilation” was coined as an observation made by clinical practitioners without investigating motive.  There are people who do mutilate their body, but that behaviour lies in the realm of psychosis, not for most of those who self-injure.

Next Up: Self-Injury – In History & Nature

Previous articles in the Self-Injury series;

• Introduction

Aaron D. McClelland, RPCc – www.interiorcounselling.com/aaron/

Self-Injury - Series Introduction

This is the first in a series of articles I will be presenting here about Non-Suicidal Self-Injury, also known as self-harm, [or by some antiquated and misguided clinicians as “self-mutilation”].  The series will run throughout September and address many aspects of self-injury from who does it and how, what purpose it serves, what biological factors are involved, what treatment options have seen the greatest success, and what those who self-injure want you to know.  I have named this series after the psychoeducational presentation I created titled:

The definition of self-injury is;

“… the commission of deliberate harm to one’s own body. The injury is done to oneself, without the aid of another person, and the injury is severe enough for tissue damage (such as scarring) to result. Acts that are committed with conscious suicidal intent or are associated with sexual arousal are excluded.”

(Winchel  & Stanley, 1991)

Self-Injury is one of the most misunderstood, mythologized, and ignored mental health issues we face.  It is a topic I became passionate about while working with adolescents who self-injure and through friendships I made in the worldwide self-injury peer support community.  I can state with confidence that I have learned more about self-injury through those who do it than I ever have reading a textbook or in any post secondary course.

I suppose the first question is; “Is this a large enough problem to even bother with?”  The short answer is “Yes.”  The statistics gathered throughout North America and Europe reveal the practice of self-injury is more widespread and more complex than most people realize.

Research conducted by Dr. Mary K. Nixon and her team at the University of Victoria (Nixon, Jansson, Cloutier, 2005) indicated the following results that have been corroborated in various other studies throughout North America;

• 16.9% of adolescents between the ages of 12 and 18 self-injured for an average of 21 months
• 75.8% were female
• Average age of onset was 15.3 years
• 58% stopped self-injuring during adolescence
• 42% continued to self-injure into adulthood
• 83.1% stated they had not used self-injury to attempt suicide

Another more recent longitudinal study (Hawton, Zahl, Weatherall, 2011) conducted in the United Kingdom that tracked 11,583 patients who presented to hospital after deliberate self-injury between 1978 and 1997 revealed the following troubling statistics on completed suicides for people who self-injure long term;

• Patients were 66 times more likely to complete suicide than the general population one year after onset (0.7%)
• 5 years after onset - 160 times more likely (1.7%)
• 10 years after onset - 226 times more likely (2.4%)
• 15 years after onset - 283 times more likely (3.0%)

To put these numbers into a local perspective, lets look at school populations in the area where my practice is located: The Okanagan Valley in British Columbia has three school districts; Okanagan/Skaha, Kelowna, and Vernon.  Applying the statistics gathered in the above study to enrollment numbers for the 2011-2012 school year;

Vernon School District 22 had 3907 students between the ages of 12-18 years enrolled.  Of those;

• 660 will self-injure for an average of 21 months
• 277 will continue into adulthood
• 8 will complete suicide within 15 years of the onset of self-injury

Okanagan/Skaha School District 67 had 4025 students between the ages of 12-18 years enrolled.  Of those;

• 680 will self-injure for an average of 21 months
• 286 will continue into adulthood
• 8 will complete suicide within 15 years of the onset of self-injury

Kelowna School District 23 had 9426 students between the ages of 12-18 years enrolled.  Of those;

• 1593 will self-injure for an average of 21 months
• 669 will continue into adulthood
• 20 will complete suicide within 15 years of the onset of self-injury

Looking at these numbers is tragic when – aside from the suicide risk - you also take into account the years of pain and suffering these individuals will endure.  And never doubt for a moment that those who self-injure for a prolonged period of time suffer torment as they enter into a cycle of self-loathing/shame, unbearable tension, overwhelming emotional distress, self-injury, and relief.  Relief that once again leads to self-loathing or shame and begins the cycle once more.

Next up: Self-injury - Mythbusting

Aaron D. McClelland, RPCc – www.interiorcounselling.com/aaron/

Brain 1.4

Many marvel at the magnificence of the human brain and the unsurpassed cognitive ability that lies within.  It is true that our brains can accomplish great feats of reason, logic, problem-solving, and creativity, but all of that is the domain of the cortex - the higher functioning part of our brain.  If we look at the systems below the cortex, we can see that the design of our brains isn’t the greatest.

Our brains - all brains on planet Earth - developed pretty much the same way, beginning with a rudimentary organ that keeps us alive: the Brainstem

This brain organ keeps our heart beating, our lungs breathing, our temperature and blood pressure regulated, and all the other systems in our body functioning as they should to sustain life.  The Brainstem is about 300 million years old and all the little critters that moved around received one.  In modern computer operating system parlance, this would be “Brain 1.0”.

The problem was that over time some critters started eating other critters, so a way to sense danger and to ensure survival of self and species was needed - we needed to be able to distinguish between friend or foe.  Instead of redesigning the brain, nature added a new system that could take care of these more complex needs - the Limbic System - and it was plugged into the top of the Brainstem about 200 million years ago.

Within the Limbic System are organs that create the desire to mate, make offspring, sense, remember, and react to everything in our environment.  The Limbic system is our guardian - it helps us survive not only as a species, but as an individual by differentiating between those we can mate with and those who pose a danger to us.  This additional system saw our brains change from “Brain 1.0” to “Brain 1.2”.

But now that our world and our functionality was becoming more fine-tuned, we needed a way to move skillfully in it, and so the Cerebellum was plugged into the brainstem and Limbic system.

The Cerebellum [Latin for “small brain”] helps us move in a coordinated way by controlling our limbs and giving us practical motor skills.  This way we can move toward others of our kind for propagation and safety, and away from those who mean us harm.  This move saw us move to “Brain 1.3”.

Armed with these developing tools, our world became more and more complex as each critter competed to survive.  To navigate that complexity - and to survive as a species and as an individual - we needed more than the basics of a Brainstem-Limbic-Cerebellum system could provide us.  And so the Cortex developed - the realm of higher functioning in our brains.  But again, it was an addition to the existing system, not a complete overhaul.

The Cortex is comprised of different areas that control different aspects of our functioning; Visual, sensory, motor, prefrontal, speech control and interpretation, plus a great deal of area that can be used as memory storage.  It’s a complex organ that sets us apart from other creatures on the planet.  So, this addition saw us move to “Brain 1.4”.

As stated above, the problem is that as our brains developed, instead of a complete redesign at each stage, the new parts were added onto the old parts like Lego blocks.  This means that all the older parts of our brain can still function without the newer parts and that is a “good news - bad news” proposition.

The good news is that as we learn new skills, such as riding a bike; We can practice and develop the skill to ride a bike using our Cortex, then assign that skill to our Cerebellum so we no longer have to think about it - we simply hop on our bike and the Cerebellum takes over.

More good news is that this system helps keep us safe by speeding up our response to danger.  Our Cortex is a wonder of computing power, but - compared to the lower parts of our brain - it is slow.  To survive a sudden threat, we need speed that is unencumbered by the slow logical processes in our Cortex.

Within our Limbic System are a number of smaller organs that each have a particular job.  Three of the significant ones are;

• Thalamus - relays sensory and motor signals and regulates consciousness, sleep, and alertness
• Amygdala - performs the main role in the processing of memory and emotional reactions
• Hippocampus - consolidates information from short-term memory to long-term memory

This system keeps us safe by monitoring our environment for danger and through other organs in the Limbic System will put us on high alert if is senses danger - and for speed, it’s connected directly to the Brainstem and Cerebellum.

When our body sends a signal up our Brainstem or through our vision or hearing, it first lands in the Limbic System.  The Amygdala immediately works with the Hippocampus to determine if this signal indicates danger by searching for memory of that same signal in the past.  If a memory matches that signal and is classified as a danger, the Amygdala triggers the release of a chemical soup that includes Cortisol [the “stress” hormone] and Norepinephrine [adrenalin] and gets the body ready for a “flight or flight” response.

What does this response look like?  Our bodies tense to get ready to run or fight for our lives - [this sometimes makes us feel weak, because groups of opposing muscles are pulling against each other]; Our heart rate increases to supply more oxygen to our muscles; Our blood pressure changes to meet the demands of our circulatory system; Our breathing rate increases to get more oxygen into our system; We may grow pale as blood is pulled deep into our bodies in case we are wounded; We may have an overwhelming need to “get out of here” or sometimes start feeling angry and aggressive as we prepare to fight for our lives depending on our nature.

This is a terrific safety system to keep us alive in dangerous situations.  Without it we would walk into traffic and pet snarling dogs.

The bad news is that because this system is designed to work on its own to make sure our response isn’t slowed down by having to consult our higher functioning brain, a fear response can cause us problems because in many cases it isn’t a real fear and our Cortex can’t stop it in time.  We end up having an “anxiety attack” without even knowing why we are feeling distress.  It would be nice to have all the systems integrated so the higher functioning parts of our brain is included in this safety system so we could consciously limit our fear responses, but it doesn’t look like “Brain 2.0” is on the horizon yet.

So, are we doomed to be ruled by a poorly designed brain system that isn’t rational and sometimes reacts to every day events with fear?

No.  There are many therapies that can address recurring anxiety problems; Our Limbic system was programmed to react to specific stimulus with fear, so we can reprogram it to recognize that many stimuli are not dangerous at all.

Therapy to reprogram our unreasonable fear responses takes courage and no small amount of effort, but until we are issued a “Brain 2.0”, we have to work with what we have.

Aaron D. McClelland, RPCc  www.interiorcounselling.com/aaron

Neural Pruning, or: "Why is my teen so impulsive?"

Almost every parent sports a few new grey hairs as their children navigate through their teen years, and many wonder why the teenage phase of development is often fraught with impulsive, reckless behaviour and raging emotional outbursts.  Rising hormone levels play their part to be sure, but a great deal of the impulsiveness we see in teens and young adults lies within how the human brain develops and organizes.  It’s all about the neurons.

Neurons are the little nerve cells in our brains that connect to each other through electrical and chemical signaling.  They comprise the circuitry of our brains and keep our heart beating, our lungs breathing, our temperature regulated and a millions other complex tasks that happen automatically to keep us alive, aware, and safe.  They are also the circuitry in our cortex that allow us to feel, learn, reason, plan, imagine, and act.

Each neuron has about 10,000 connections to other neurons.  At the time of our birth we have about 10 billion neurons, but our brains continue to grow into our teen years and will reach 80 billion to 120 billion in number.  So taking an average of 100 billion neurons, each with 10,000 connections gives us 1,000,000,000,000,000 circuits inside the confines of our brains – each capable of activating as we encounter a new stimulus or choice.  And with that many active connections, a teen’s brain is a pretty busy place.  And sometimes it’s a confusing place as the neural connections compete with each other – and this is why we often see the poor judgment, impulsiveness, and at-risk behaviour in our teens.  This is also why we see the rapidly cycling highs and lows of emotion and why some teens resort to drugs or alcohol or self-injury as a means dial back the sometimes overwhelming activity inside their head.

So why do we have so many connections that they actually seem to cause us problems?  It’s because the brain is designed around redundancy – we have two of almost everything we need and – as noted above - way more connections than we require.

Now here’s the good news; Because nature intended us to have more neural connections than we need, it also provided our brain with a means to organize those connections.  As we mature, our brain prunes excess connections.  First, little-used connections are pruned as part of a “use it or lose it” strategy.  Second, troublesome connections are pruned – connections that duplicate messages that create that impulsive behaviour or raging emotions are cut out.  Outwardly, we see this as “learning” and “maturing”.

This pruning process starts in infancy and is completed in early adulthood, which is why we see our wild teenagers gradually calm down as they approach their mid 20s.

So, knowing why our teens seem to be out of control at times won’t slow the greying of our hair, but it will hopefully help us to understand that these behaviours are a normal stage of development and will one day pass.

Aaron D. McClelland, RPCc  www.interiorcounselling.com/aaron

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“Happy Thought Therapy” Can Be Deadly

We’ve all seen them; Those “happy thoughts” little posters that are plastered all over the internet, especially on sites such as Facebook.  They’re supposed to uplift our spirits and help us remain mindful of how wonderful life really is.

What is truly alarming, however, is when mental health practitioners – some armed with very little knowledge of how deep some psychological wounds can be – build their practice around this “happy thoughts” fad.  Unfortunately I see far too many people claiming to be counsellors or therapists who have built their practices around this pop-culture, quick-fix trend, some going so far as to declare all other therapeutic approaches and psychiatric measures as part of a global conspiracy to keep people ill.

Let me be clear in my message: Being exposed to prepackaged “happy thoughts” WILL NOT cure serious mental illness, nor alter an Axis II personality disorder, nor alleviate the devastating symptoms arising from exposure to trauma, such as war, rape, child abuse, or sexual abuse.

I call upon my colleagues who employ this simplified “think yourself happy” approach to mental health issues to do some serious reading of current research, especially in the field of neuroplasticity and epigenetic research.

An example to illustrate my point is research conducted at McGill University in Canada and published in January, 2011, that found early childhood trauma not only impacted the function and structure of the brain, but also altered the expression of DNA in the affected person.

For “The epigenetics of social adversity in early life: Implications for mental health outcomes”, [McGowan, et al, 2011] researchers studied the brains and DNA from 24 men who had been abused as children and completed suicide.  They compared their findings with those from men who had died suddenly through accidents or suicide and had no history of abuse. 

Their findings indicated that the men who had experienced early childhood abuse had altered function of the hypothalamic-pituitary-adrenal axis [HPA] – this is a trio of glands that produce an array of hormones including cortisol, the “stress hormone”.  The NR3C1 gene is part of this system and produces a protein called a glucocorticoid receptor that sticks to cortisol.  When cortisol latches onto this receptor it triggers a chain reaction that deactivates the HPA axis, dialing down the body’s response to stress.  In those who experienced early childhood abuse, the NR3C1 gene is often blocked from proper function.

With diminished glucocorticoid receptors, the body’s affect-control system becomes dysfunctional and the HPA remains active in normal situations as well as stressful ones.  A person’s ability to tolerate stress is severely compromised and the result may find them living in perpetual distress which can lead to anxiety disorders, depression, and suicide.  This state of being is not the fault of the affected individual and no amount of “happy thoughts” will change the epigenetic damage that early childhood abuse caused.

But how does a person who is struggling with post traumatic symptoms feel when all around them, people purporting to be counsellors and therapists are espousing the effectiveness of simply “thinking yourself happy”?  How does that person feel when no matter how hard they try, their symptoms persist?  Are they able to recognize that it is the “therapy” that is the failure?  Or do they conclude that they are?  And there-in lies the danger of declaring a single pop-culture technique as a cure-all for mental or emotional problems.

This is not to say that there is no hope for those whose HPA system has been affected.  Recent studies into the efficacy of a number of therapeutic approaches such as Trauma-Focused, Dialectic, and Cognitive Behaviour Therapies, Eye Movement Desensitization & Reprocessing, and other techniques, combined with tailored mindfulness practice have shown remarkable changes in the brain’s function and structure.  But any therapy must be tailored to fit the individual and the therapeutic goals and pace must be arrived at in collaboration with the individual.

My greatest fear is that an individual who struggles daily with distressing thoughts and feelings as a result of abuse, will bypass proven successful approaches by trained and experienced therapists and buy into the “happy thoughts” trend - Then do their best playing a game they cannot possibly win and declare themselves a failure, losing all hope and begin to believe that the only relief they will find lies in suicide.

To those practitioners who employ this “happy thoughts” philosophy, please cease claiming it is an answer for all mental health conditions.  Presenting such philosophies falls in the realm of a life-coach, not a therapist.

To those who find themselves experiencing ongoing distress from trauma, I would offer the words of Jamie Tworkowski, founder of To Write Love On Her Arms; “Hope is real.  Help is real.  Your story matters.”  Keep searching until you find a therapist who will truly listen to you and offer real therapeutic interventions, not just a rehash of slogans from internet feel-good posters.

Aaron D. McClelland, RPCc  www.interiorcounselling.com/aaron

Home Therapy Sessions

As a practitioner in the mental health field, I am very aware that there may be serious barriers that prevent people from traveling to my office to find the help, support, and therapy they may require.  Examples of these barriers can include; depression; agoraphobia; contamination phobia; obsessive-compulsive issues; suicidality; hoarding; cultural preferences; transportation limitations; physical challenges; dependant children or adults they cannot leave unattended.  For people who face these and other challenges, Home Therapy Sessions may be the answer.  Others may require home visits to help them learn and develop parenting or life skills.

In order to best serve those in need, I have chosen to offer home visits for consultation, assessment, and therapeutic counselling on a case-by-case basis.  Any client wishing home visit counselling will be asked to weigh the pros and cons, and to determine if they can meet the conditions for a therapeutic visit to take place.

Advantages

The main advantage of Home Therapy Sessions is comfort for the client - it removes the stress or inability to travel and allows them to remain in a familiar and - hopefully - safe environment.  For the therapist it allows us to see our client on their home turf, allowing for assessment and therapeutic interventions to take place in context and helps us understand the client better following the adage “Health isn’t a diagnosis, it is how we live.”

Therapy sessions can take place anywhere appropriate; in a living room, porch, backyard, car, nearby park, library, school, church, during a car ride or a walk on a trail.  So long as the chosen place is safe and conducive to building a healthy therapist/client relationship and is free of danger, the choice of location for the session is unlimited.

Another advantage of Home Therapy Sessions is that they can help reduce Emergency Room visits and hospitalizations by dealing with problems before they become a crisis.

Boundaries

The therapist and client must establish healthy boundaries both for the client’s protection and to help the therapist maintain their role.  Because it is outside of the office structure which is designed to be free of distractions, a home visit can be more fluid and unpredictable, such as; other family members present in the home; pets; phone calls; friends visiting unannounced.  Because of this, the therapist and the client must agree on ways to minimize these distractions.

The Client & Therapist Roles

It is important during Home Therapy Sessions to maintain the roles each person has in the therapeutic relationship.  The therapist is not a “guest” in the home, they are there in a professional capacity.  Clients should understand that they do not have to cater to their therapist as they would a friend coming to visit and understand that the therapist isn’t being rude if they decline the offer of a snack or beverage.  The other rule for therapists that is the same whether in their office or in a client’s home is - they cannot accept gifts.  To do so can result in the therapist being brought before a disciplinary board of their association and may have their right to practice removed if the incident is serious enough.

Session Length and Fees

The length of sessions for each client is up to each therapist to determine; depending on how the session progresses or the issues involved, many therapists [myself included] will work to what is known as “end point” instead of sticking precisely to the clock.  That is; to complete the therapeutic part of the session even if it goes over the one hour time limit by 15 minutes or so.

It would seem logical to assume that the hourly rate for a home visit would be less than an office visit, because there is no need for the overhead costs of maintaining an office.  However, most therapists who offer home visits also maintain an office where they complete their session notes, do research on behalf of clients, and consult with other professionals on general topics that can benefit their clients.  The other costs to the therapist doing home visits is travel time and expenses that can amount to more than the hourly in-office percentage.  So, typically, Home Therapy Sessions are not discounted for those reasons.

Safety & Confidentiality

Great care must be taken both by the therapist and the client during home visits to maintain safety for all and confidentiality for the client.  For example; It would not be good practice to have an abusive or controlling spouse or child present during the session.  Neighbour and friend visits should be discouraged during the session, and care must be taken to ensure no one can hear what is said during the confidential session - The same rule in the office must apply at home; “What is said in session, stays in session.”  it is the client’s decision on what they share with their family and friends.

Another issue that cannot be compromised is the use of alcohol or illicit drugs prior to or during a session.  If the client has or is consuming either alcohol or mood-altering non-prescription drugs prior to or during the session, the therapist will end the session immediately and offer to book a new appointment.  Clients should understand that if this occurs, they may be billed for part or all of the terminated session.

Providing for healthy boundaries, Home Therapy Sessions can be a positive option for some clients.  If you or someone you know might benefit from a home visit by a therapist, please contact one in your community to see if  they are willing to offer this service.

Aaron D. McClelland, RPCc www.interiorcounselling.com/aaron