Counseling Today, Cover Stories

Growing Pains

Lynne Shallcross March 15, 2010

It was Tiffany Craig’s turn to do a “squiggle story.” She had drawn a squiggle on a piece of paper and, out of respect for her young client, took a turn imagining what the squiggle might be. Craig, who runs a private practice in North Laurel, Md., determined the squiggle resembled a dog and set about creating a collaborative story with the client. In the story, the dog encountered a girl and wanted to be her friend and help her.

When the girl, played in the story by the client, rejected the dog, the dog began wailing comically. “The client laughed and decided to let the dog sit at her feet if the dog promised not to slobber too much. Eventually, she said, they became friends,” Craig recalls.

Below the surface, the story was about much more than a dog and a girl, Craig says. The client was ambivalent about trusting Craig as a therapist, and Craig noticed that the story paralleled what had been taking place in their own relationship. But after the squiggle story, the client began talking much more candidly about what was going on in her home. “She just needed to know I wasn’t going to ‘slobber all over her,’” Craig says. “I read that as me not gushing over her boundaries and overwhelming her with words the way many

s to learn more about how the field is changing and how counselors can best serve these clients.

adults have in her life. If my interpretation is wrong, she will show me in whatever way makes sense to her. If I’m paying attention, I’ll get it.”

Whether it’s squiggle stories, sand trays or seashells, counselors often have to find unique ways of reaching and, ultimately, helping child and adolescent clients. Counseling Today spoke with Craig and four other American Counseling Association member

Tiffany Craig

Counselors who work with children had better know their stuff, says Craig, whose experience also includes working at a pastoral care center and providing school-based therapy in Baltimore City Public Schools. “With adults, you can fudge a little bit here or there without your misguided efforts creating too much disruption to the process. With kid clients, they will tell you immediately if you have ceased to speak English, slipping into psychological gibberish. You have to really comprehend what you are doing and why — your therapeutic framework — if you are going to translate it to a client who is 3 or 4 years old and apply it to the age-appropriate interventions you choose.”

As with the squiggle story, Craig says she tries to speak the language of her clients, always taking into account their age and developmental stage. That may mean creating or listening to music, storytelling with stuffed animals, sand tray therapy, therapeutic games or arts and crafts. Sometimes Craig and her clients go to the creek behind her home office, pick five objects at random and then create a story involving the objects.

“Whatever scenes they need to work out always come out,” she says. The challenge, she cautions, is not to over-interpret the stories, but rather to get a general sense of what is happening between the characters and what is in the client’s world and normal frame of reference. “I watch where they’re going (with their stories) and listen for places where they are hurting or conflicted,” Craig says. “Once identified, and if I have permission, I will enter into their world through their chosen modality and introduce alternative, more functional and healing concepts.”

One major advantage to working with younger clients is that they naturally tend to show counselors where they need to go, Craig says. “Most child clients lack the layers of self-protective, analytic mind blankets with which adults insulate their psyches. For example, when children tell progressive stories with you, they are often able to free their minds to totally invest in the story without trying to manipulate a predetermined outcome. This gives them a much more honest, helpful and complete psychological process.”

As she does with adult clients, Craig reminds her child and adolescent clients that counseling is a collaborative process. “I know a few things about psychology, relationships, emotions, brain chemistry and all that, but the client is the expert on his or her own life. Child and adolescent clients tend to automatically grasp that in the work. They are exceptionally adept at leading us — the clinicians — in the directions in which they need to go. Just as with adult clients, our job is to follow using genuine respect and appreciation for the deeper wisdom the client embodies.”

Craig’s child and adolescent clients deal with issues ranging from depression, anxiety and lack of focus to grief, trauma and major life changes. Craig has also noticed newer issues related to children’s interactions with technology. “I’ve worked with a number of kids who were already struggling socially but who have become consumed with things like Xbox and PlayStation, to the detriment of sustaining friendships and building functional social skills,” she says. Craig also questions whether children’s and adolescents’ capacity for working out problems might be taking a hit. “It has become normative to simply end conversations midstream if a conflict arises,” she says. “We can easily blame such avoidance behaviors on the technology — my cell hit a bad spot; my Internet went down. I do think that the current crop of kids is coming up with some deficits in the area of being able to tolerate distress long enough to work things out with others. They’re used to having an easy out.”

Craig agrees with the family systems theory that counselors are treating an entire system, not just the client sitting across from them, so she makes working with as much of the family as possible a priority. Although many of the kids Craig sees have only one custodial parent, she always extends an invitation to the noncustodial parent to be involved in the counseling process. She won’t agree to see a young client without the knowledge and, normally, the consent of both biological parents, even if only one parent has legal decision-making authority. “I am also very clear with parents that my intention is to support their work with their kids in any way that I can. I believe it is critically important to the process that the parents know I hold their role in utmost respect and that I am well aware they know their kids better than I do.”

Craig acknowledges her boundaries working inside a family system, meaning that although a child can make good progress in counseling, the home or school system might not support that progress. “It’s a wonderful reminder of what our job is and isn’t,” she says. “J. Eric Gentry, a good friend of mine and a trauma specialist in Florida, frames this beautifully when he reminds me, ‘The results of your work are none of your damn business.’ I do believe he’s right. We come and give what we have to give to the best of our ability. What the client does or can do with what we give is completely — and appropriately — beyond our control.”

In an effort to create a community for parents and offer a checkup for former client families, Craig developed the Parenting Coach’s Blog (theparentingcoach.wordpress.com). Her mind-set with the blog is that an ounce of prevention is worth a pound of cure. “I honestly believe that being aware as a parent is a good 80 percent of the battle,” she says. “When we are aware of our own triggers and what’s going on inside of us, we are able to be intentional, to be humble and to be a positive force in our children’s lives.”

“Parenting is exhausting and can leave you doubting yourself at every turn,” she continues. “Parents need support and encouragement just like their kids do. I make an assertion on my website that I absolutely believe: The two hardest things in life are being a child and raising one. Well-supported, empowered, aware parents have a good shot at raising competent, capable, well-adjusted kids who grow up to live out of their true selves, take hold of their lives and bless the people around them. That’s my goal.”

Norine Lyons

Norine Lyons remembers exactly what inspired her to specialize in working with children. After many years in corporate public relations, Lyons earned her master’s in counseling psychology and spent her practicum at a residential substance abuse treatment facility for adolescent boys.

“It was always amazing how some boys could come into treatment looking completely wretched and angry or just forlorn, and then, in a few months of regular meals and structure and chores and therapy and time away from family dysfunction or community distress, you could see someone start to emerge from all that pain and anguish. Not all the time, certainly. Far from it. But it was exciting when you could see the changes a boy could make, start to imagine a good life for him, and you could see that he could see that for himself,” says Lyons, who earned a certificate in child and adolescent psychotherapy from the Washington (D.C.) School of Psychiatry before starting her Alexandria, Va., practice in 2008.

Children and adolescents face many of the same issues as adults, says Lyons, who also sees clients at a private practice in Washington, performs pro bono work and spends one day a week at an agency that provides care to at-risk children and their families. “They face everything their families face. Loss of a parent to death or illness or divorce or incarceration, those are the biggest and the deepest losses. There’s the loss of friends whose families move away. They worry about terrorism, war, bullying; about their parents losing their jobs; that their parents fight; that nobody likes them; that school is too hard; that they don’t look the right way; that parents and teachers expect too much from them; drugs, alcohol, pregnancy, gender identity issues, paying attention, depression, anxiety. Quite touchingly, children worry a lot about the happiness of the people they love.”

The way more “mature” topics are presented and shared today also affects the youngest among us, Lyons says. “I think the barrage of information that children are exposed to has to have changed things (for them). A fairly persistent 12-year old a couple of generations ago could scare himself to bits by reading a newspaper, but at least you had some idea of what he was reading. The Internet has changed all that, as has the level of violence and other material that’s out in the ether now. Children aren’t wired to handle it, and it can create enormous distress and anxiety. Worse, they get used to it and accept it as normal.”

Another issue Lyons believes is affecting children and adolescents is a loss of freedom. “I read about a study in England that looked at children’s ‘radius of activity’ — the distance from home that kids could play unsupervised. It had declined by 90 percent since the 1970s,” says Lyons, who estimates that figures in the United States would look pretty similar. “Kids used to wander off on a summer morning with instructions to come home before dark. They invented their own games and went off on adventures and organized their own fun. No parent in his or her right mind would be OK with that today, and with good reason. But you have to wonder about the loss to children — of flexibility, resilience, creativity, of fearlessness and feeling powerful. It’s hard to feel powerful on a play date.”

Counseling teaches practitioners to meet clients where they’re at, and that includes with young clients, Lyons says. “When you work with children, you meet them sitting on the floor. Kids need to play. It’s how they show you what their world is like, and it’s how they heal.” Having the right mix of toys is key to encouraging self-expression, says Lyons, who believes the most valuable objects in her office are a sand tray and roughly 400 miniature figures, which range from animals and adult and child figures to wizards, kings, angry villagers, superheroes, tiny beer cans, wishing wells and a tiny Eiffel Tower.

“You show the child the miniatures and the sand tray and invite her to build a world in the sand,” Lyons says. “A boy that I worked with very briefly had a great deal of trouble with anger, and he had a lot to feel angry about. He would line up the horses tightly in one small corner of the tray and then put row after row of fences in front of them. It was all right there in the tray — all the feelings he didn’t have words for. Another little girl who was missing her father would do these very elaborate trays where the king was always forgetting about the princess. For some children, using human figures is too threatening, too evocative, but they’ll play out stories and themes using animal families.”

Lyons also keeps a bowl of seashells in her office to help her young clients with relaxation. She invites children to pick a shell that they like and to carry it with them. She then teaches them to imagine the beach or some other place where they feel calm and peaceful as they hold the shell. “Older children are especially interested in the idea that they can do things to change the way they feel,” Lyons says. “It gives them a sense of control and mastery.”

Another go-to game in Lyons’ office is an adaptation of Jenga. Lyons took a Jenga set and labeled each of the wooden blocks with feeling words such as disappointed, furious, excited and surprised. As clients remove a block from the tower, they read the word and talk about a time when they experienced that feeling. “This is a good one to do with siblings,” Lyons says, “and it’s often interesting to see how they remember feelings for each other. ‘Furious — that’s like how you were when we didn’t go to McDonald’s.’” The game is also helpful for teaching children words to express their feelings, she adds. “Some children have a real poverty of expression when it comes to emotions. They can’t get much beyond good and bad. The more you can enlarge children’s feelings vocabulary, the more you can help them make sense of their emotions instead of feeling overwhelmed by them.”

The parents and family always play a part in the counseling process when your clients are children and adolescents, Lyons says, but to what degree depends on the age of the child and the nature of the problem. Although many problems involve the parents, Lyons says it would be too harsh to say that parents are often the cause of their children’s problems. “For the most part, parents want to do well by their children and are usually very distressed when things go wrong,” she says. “Or they’re unaware of how their actions affect their kids. A parent may not realize that a child feels abandoned while mom or dad sits in front of the computer for hours or talks on the phone.”

In some situations, Lyons says, there’s simply a poor fit between parent and child, such as when a parent is loud and enthusiastic while the child is quiet and introverted. “The child can feel quite overwhelmed by the parent,” she says. “So you gently teach different ways for the parent to interact with and communicate with the child, dialing it back a bit to suit the child’s temperament.”

A bulk of the work is helping parents understand their child’s temperament and developmental level, Lyons says. “You’ll see a child who has frequent explosive behaviors and is labeled defiant or manipulative by the adults in his life. So you try to help (the parent) understand that it takes a lot of social skill and planning and patience to be manipulative — this child isn’t capable of that. He isn’t having a meltdown to get his way. He just doesn’t know what else to do.” In this instance, the child’s social skills, planning abilities and communication skills need work so he doesn’t have to explode, says Lyons, who adds that Ross Greene and J. Stuart Ablon address the topic of the “explosive child” particularly well. “If you can help a parent to see a child in a different light, the parent is better able to empathize with the child’s struggle and more motivated to help,” Lyons says.

Lyons says she remains struck by the privilege of working with children and their families. “In everything, the goal is to strengthen the bond between parents and children. It takes great courage and compassion for a parent to bring a child to counseling, as well as a leap of faith. As a counselor, I always feel honored and humbled by that.”

Michael Michnya

Ask Michael Michnya if children and adolescents are facing different issues today than in years past, and he’ll answer yes — and no.

“Our basic biology hasn’t changed in thousands of years, and our basic developmental tasks and challenges are the same. However, the context in which children and adolescents undertake them has (changed). The pace of life is faster, the amount of information to be processed is greater, and the world is smaller. Yet our hardware — our brain, senses, muscles, organs, etc. — is the same hardware we developed for survival in more primitive times,” says Michnya, manager of the Family Preservation Services (FPS) program at the Family Service Association in Atlantic County, N.J., which provides brief, intensive home- and community-based counseling to families with children at risk of out-of-home placement.

Quite possibly the biggest change thrust onto children in the past few decades has been the whittling away of personal adult involvement, Michnya says. At one time, many children grew up on farms working alongside and learning from their parents. But the onslaught of technology led to a gradual decrease in face-to-face contact, a spike in the divorce rate shifted family dynamics, and schools changed in such a way that even young students often have multiple teachers or face higher student-to-teacher ratios. “At just the time when children are getting ready to enter adult society and most need mentoring and contact with adults, they’re getting much, much less than ever before,” Michnya says. “It’s no wonder that sites like Facebook and MySpace are so popular, but it’s a case of the blind leading the blind.”

Play therapy is Michnya’s preferred approach when working with children younger than age 12 or 13. “I generally give the child anywhere from 30 to 60 minutes per session, divided between free play — in which the child chooses what toys he or she uses and I follow, commenting on choices and identifying emotions — and mutual therapeutic storytelling, which either begins or ends the session,” says Michnya, who also runs a private practice and specializes in helping parents develop the skills they need to be more effective with their children, regardless of the presenting problem.

One game Michnya finds particularly effective with his young clients is “Mr. Mike’s Story Time.” With this approach, which Michnya adapted from a previously developed method, the child tells an original story, and Michnya then retells the story with a healthy theme or outcome. “The idea behind the technique is to give the child the opportunity to express him- or herself in a different way, while at the same time giving me clues about some of the issues I might need to address. (It is also) an indirect way of giving the child suggestions, ‘seeding’ them by embedding (the suggestions) in the stories I tell.”

With teens, Michnya uses a motivational interviewing approach in which he demonstrates understanding and empathy. No matter the reason for a teen seeking counseling, Michnya says his basic approach is the same: provide active listening plus validation, give accurate and helpful information and offer possible solutions with a focus on the potential consequences of those choices.

Another technique Michnya has adapted for his work with teens is “Write, Read and Burn,” which he says helps clients overcome troubling memories and the powerful emotions often associated with them. With this technique, clients carry a small notebook to record emotions or memories that interfere with their functioning. At the end of the day, clients read what they wrote, tear it out and burn it. “It’s helpful for the client to watch the flames consume the paper and to imagine the smoke carrying off the pain and memories,” Michnya says. “They then dispose of the ashes by scattering them to the wind, flushing them down the toilet, etc., and then they go to sleep.” Michnya says he suggests that parents supervise the “burning” aspect of the technique and adds that he would never assign this technique to a client who is at risk for fire-setting. Michnya sometimes uses the technique with children but replaces “burn” with rip or shred.

Do the issues children and adolescents present with in therapy often circle back to the parents? “In a word, yes,” Michnya says. “Most of the parents that I work with in my practice and in the FPS program complain about the same things — noncompliance, disrespect, sibling rivalry and problems in school behavior and/or performance.” Usually, he contends, these behaviors are caused or made worse by ineffective parenting, though he adds there are definite exceptions, such as when children have brain damage or are affected by personality disorders, learning disabilities or biochemical affective disorders.

“Most parents are ‘good’ parents in that they want the best for their children and try their best to raise them right,” Michnya says. “But because most parents see themselves that way, they don’t always consider how their own behavior maintains the problem or makes it worse. Among our natural drives are those for mastery of and autonomy in our environment. It’s a tricky business to know how much freedom and responsibility to give a child as he or she grows, and parents often err by giving both too much and too little.” That could mean too much freedom and too little responsibility, or some other combination, Michnya says. “Children and teens are simply responding to the environment that their parents and other caregivers create, trying to satisfy their needs and wants in the most direct way possible. They don’t have the fully formed cognitive ability to consider the consequences of their actions.”

Scott Riviere

“My Crappy Life” probably isn’t a name you’d expect to hear for a therapeutic game targeted at teenagers. But in Scott Riviere’s counseling office, it has worked wonders.

Riviere, who runs a private practice in Lake Charles, La., recalls a 13-year-old client who, while not resistant, didn’t want to talk. The boy’s parents had divorced when he was very young, and his father had died about six months before the boy came to see Riviere. His mother was worried that he hadn’t processed the death, so she brought him to therapy.

Riviere, who knew the boy was into the Louisiana rodeo scene, decided to appeal to his interests. Riviere took a large piece of paper and began drawing piles of cow dung — big piles and little piles, some with flies around them and others with steam drifting into the air. When Riviere saw the boy smile, he knew he had him hooked.

Riviere explained that the drawing was called “My Crappy Life,” and the boy’s job was to list the “crappy” things that had happened to him in the piles of dung. Really terrible things were to go in the big piles; bad, but not terrible, things were relegated to the smaller piles. Riviere gave the boy some privacy to write, and when he had finished, Riviere asked him which of those life events he wanted to do something about. The boy picked his father’s death. The boy still had trouble talking, but through the game, Riviere had found another way in. “Did he communicate with me?” Riviere asks. “Absolutely.”

Many times, children just don’t have the words to communicate, Riviere says. It’s in these instances when adding creative interventions and play therapy can help. Because play is a behavior, it connects with children and adolescents on a mechanical level — the behavior-focused, first stage of human communication, says Riviere, a member of the Association for Play Therapy. “It meets the person at that primitive form of communication, which you know they’ve mastered. If they want to talk, you should talk. It’s not about forcing them to do anything. It’s just a type of communication you can virtually guarantee most humans have mastered.”

Riviere calls one of the play therapy techniques he adapted to use with young clients “Heartfelt Feelings.” He gives clients a sheet of paper with a heart on it, and clients color in the heart based on how they’re feeling, using different colors to signify emotions such as happy, sad, mad and worried. In one variation, the heart can indicate how much of each different feeling the client has experienced in the past month. In another variation, the client can color in the heart based on how he feels about a specific topic or situation, such as his parents’ divorce, for example.

Riviere also uses a sand tray to allow clients to reenact events using miniature figures. The miniatures should reflect the client population and their environment, Riviere says, adding that he took the leaves and branches off miniature trees after Hurricane Katrina so clients could use them to tell their stories. Not only can reenactment help with desensitization, he says, but it also puts clients in a position of power instead of helplessness.

Another game Riviere plays with his young clients uses dried beans and plates with happy, sad or mad faces. The idea behind the storytelling exercise is that people can have a variety of emotions attached to a single event, he says. The child places a specific number of beans on each plate, indicating how much of each emotion is involved in a given situation. The stories children tell tend to deal with things going on in their lives, Riviere says. “(With this exercise), they can tell you how they feel about things without having to express it verbally.”

Riviere admits games aren’t necessarily ideal for working with teenagers. Instead, the important thing to focus on with that age group is creating a relationship, he says. Once you create a relationship with teenagers, they’ll allow you to have some influence, he says. Not sole influence, Riviere emphasizes, but teenage clients are much more likely to listen to what the counselor has to say if that counselor has invested in establishing a relationship with them.

Creating a good relationship with teen clients can involve more than spending time together during regular appointments. “They don’t do well with ‘You’re only important to me during your session time,’” Riviere says. The interview Riviere scheduled with Counseling Today was delayed 20 minutes as he talked on the phone with a teenage client whose boyfriend had just broken up with her. “That’s not a clinical emergency in the adult world,” Riviere says, “but in a teenager’s world, that’s a big deal.” Riviere allows his teen clients to text or call him during off hours and says he has yet to have a problem with anyone abusing that access.

Openness and honesty are also important in cultivating a relationship with teen clients, Riviere says. Although counselors are trained to maintain boundaries, Riviere has found that teens are more hesitant to reveal details of their lives if the sharing isn’t going both ways. However, Riviere says, counselors must ensure that self-disclosure is done only in service of the client. He offers as an example the time he told a client about his own father’s death because the client was going through the same situation.

One game Riviere does find helpful with teens is throwing spitballs at a poster of cartoon faces with corresponding emotions. “It’s just a lot more in tune with a teenager’s natural tendencies to want to break rules and push limits,” he says. Wherever the spitball lands determines the particular emotion Riviere and the client will talk about. Part of developing the client-counselor relationship is engaging in activities with the person, Riviere says. That’s why he also takes turns throwing spitballs and talking about emotions. In the process of telling a story of his own, he says, he might help to validate something the client has gone through. “It’s always in service of them,” he says.

Katrina Schurter

Sometimes, the most important objects Katrina Schurter brings to a therapy session are blue poster board and art supplies.

On her first visit with a client and client’s family, Schurter, who works as a counselor at a Peoria, Ill.-area nonprofit organization, often asks them to make a “family aquarium” using the art supplies, which might include everything from seashells and feathers to pipe cleaners and squiggly eyeballs. The result? An “endless” amount of information about the family and its dynamics, says Schurter, who, in addition to treating high-risk, low-income youth at their homes or schools through the nonprofit, also works with a group practice in Peoria.

Each family member makes his or her own sea creature, which offers a potential window into each person, Schurter says. Then the family as a whole decorates the body of water and puts their creatures in. “This is a great opportunity to read into family dynamics,” she says. “Who is in charge in the home? How do siblings work together? How do parents work together? Is anyone isolated?”

“I’ve seen aggressive children in the home make creatures such as sharks that are chasing other siblings,” Schurter continues. “I had a parent once who made an octopus that symbolized how he was always trying to chase down all five of his children. It can be a phenomenal assessment tool to determine where you want to go with the family from that point on.”

The family aquarium is just one technique Schurter uses when working with her young clients, who struggle with issues including oppositional defiant disorder and conduct disorder, self-mutilation, anxiety, bipolar disorder and anger management. But as with the family aquarium, many of her therapy techniques involve the whole family, not just the young client. “When the child is the client, the whole family is the client. This just means that the child has been identified as the ‘problem’ and is showing the most disruptive behaviors, which usually are caused by the dysfunction of the entire family. Unless I am working with a child with a specific kind of developmental disorder such as autism or Asperger’s (syndrome), I work with both parties,” says Schurter, who has also provided counseling for juvenile sex offenders and kids in foster care.

When structure is lacking in a client’s home, Schurter helps the family create behavior charts and often involves older children in choosing consequences and rewards for certain expectations. “Tier-consequencing” can help, she says. “The first consequence for bad behavior (involves) the child doing something extra to make up for the behavior rather than losing something. For example, a mother might tell the child they have to wash all the dishes again if they leave some of them dirty in the sink. If they refuse, then they lose some kind of privilege. After awhile, the children start to do the first consequence because they don’t want to lose anything.”

Working with the entire family is crucial, Schurter says, because it’s common to see children struggle with issues that can be traced back to parenting style or a dysfunctional dynamic in the home. “This is basically structural theory, but I believe it with all my heart,” she says. “If you work on changing a child and they go back into the same environment day after day, the family members work against what you are doing, many times subconsciously, because if that client changes their behaviors, then everyone else has to respond differently to them and, thus, change their behavior. As much as they believe they want the child to change, they themselves do not want to, and they need to have it explained to them that they all must change.”

It’s not enough for counselors to simply work with a young client’s parents; it’s important to develop a positive rapport with them, Schurter says. “I have found that when I have a positive relationship with the parents, the children respond better to me. Yes, even the ones who say they hate their parents and outright verbally and physically abuse their parents. … Even if they act like they hate you (the counselor) in the beginning, I believe deep down, they are grateful that someone has come into the picture to help their parents and give them some structure in their life.”

Working with children often involves a greater degree of responsibility for the counselor, Schurter says. “With adults, we are taught to do most of the work the first few sessions, but then we should not be doing more work than our clients. But with children, I believe I should try harder and work more to build rapport if they are resistant due to the … research that proves there is a higher chance for change the younger the client (in therapy) is. I believe that children are, at least partially, a product of their environment and, therefore, deserve more effort than an adult who is able to make their own choices and has already had years of experience in life.”

Lynne Shallcross is a senior writer for Counseling Today. Contact her at lshallcross@counseling.org.

Letters to the editor: ct@counseling.org

Expert advice

Counseling Today asked ACA members Tiffany Craig, Scott Riviere, Norine Lyons, Katrina Schurter and Michael Michnya for their best advice on working with children and adolescents. Following are 20 tips to help counselors working in the field.

  • DO respect the wisdom of your clients, regardless of age, Craig says. “A 2-year-old is not less wise than a 92-year-old. They just have a different kind of wisdom. Tune into it! They’re amazing.”
  • DO deal with your junk, Riviere says. Having the perfect childhood isn’t a requirement for being a good counselor, but dealing with your baggage from childhood is.
  • DO build strong collaborative alliances with parents, Lyons says. “Even if you’ve developed great rapport with the 14-year-old client, he won’t be coming back if you’ve alienated his mother or father.”
  • DO relax, Craig says. “Don’t forget that kids are psychic and will read any insincerity or anxiety in you in a heartbeat. You can’t fake it.”
  • DO build on strengths, Craig says. “Human beings learn and genuinely grow by building on what we do well.”
  • DO be hopeful, Schurter says. “Even if you are not, convince yourself there is always hope. If you are not, the client will pick up on it.”
  • DO tell lots of therapeutic stories, Michnya says.
  • DO be gentle and empathic with your recommendations, Lyons says. “Remember how difficult it is for the parent to be in this situation and how wary he or she may feel about being judged or seen as the reason for the child’s struggles.”
  • DO give children and adolescents work to do outside of session, unless they are extremely young, Schurter says. “This will help empower them and help them take responsibility for their change.”
  • DO separate the person from the behavior, Craig says. “Human beings are intrinsically valuable, even children who act like hellions and grown people who harm children. Their behavior is what is in question and needs care. We get much further toward lasting healing when we honor this principle in our work.”
  • DON’T ignore the family system, Michnya says.
  • DON’T assume you are the expert, Schurter says. “Give parents and adolescents empowerment by reminding them that they are the experts. They will be more willing to do the work if they believe they are the reason for the change, not you.”
  • DON’T underestimate the ability of a child, for good or ill, Craig says.
  • DON’T try to lead until you have an excellent relationship, Michnya says.
  • DON’T see a child without the full knowledge and consent of all legal parents and guardians, Craig says.
  • DON’T cast negative light on important people in a child’s life, even if those people are harming the child, Craig says. “They need those powerful internal objects intact.”
  • DON’T promise something you can’t deliver, Michnya says.
  • DON’T work with children who have issues you are not trained to treat, Schurter says.
  • DON’T keep secrets that have to be told, Michnya says. “The most common one that I’ve encountered is when counselors know about an abusive or neglectful parenting situation and, instead of reporting it to Child Protective Services, keep it to themselves.”
  • DON’T get into kid therapy unless you are willing to sit on the floor, play by the creek, get your clothes covered with paint, pick up a bug, deal with snotty noses and play for a living, Craig says.

– Lynne Shallcross

Caring for the youngest among us

An expert in infant mental health shares what counselors need to know.
By Nancy L. Seibel, M.Ed., NCC

Editor’s note: Nancy Seibel is a member of the American Counseling Association, an infant mental health specialist, and a doctoral candidate at George Mason University.

The idea that babies have mental health can bring up the absurd image of a 1-year-old stretched out on an analyst’s couch, earnestly describing last night’s bad dream. Counselors may wonder if there is any reason to be concerned about babies’ mental health. Assuming there is such a thing as “infant mental health,” further questions arise about how early mental health can be supported, and how difficulties that arise so early in life can be treated.

In counseling, we tend to focus our training and work on people from kindergarten through adulthood. The notion that even very young babies and toddlers can suffer mental health disorders and that these can be treated can be very surprising. What may initially be easier to understand is that disorders and struggles seen later in life often have their roots in the earliest months and years.

Early development is the result of the interaction of nature and nurture.(1) We all come into the world wired to build relationships with important caregivers and eager to learn. We also bring with us our genetic potential. How that potential is expressed has to do with the nature of the environment around us. That environment includes our network relationships with those who take care of us routinely, other close family members or family friends, as well as the surrounding physical environment, community, society and culture.

Most of us picture the early years as a time of wonder and exuberance. The term infant mental health (IMH) references both wellness and disorder. ZERO TO THREE’s Infant Mental Health Task Force defines IMH as the developing capacity of the child to experience, regulate and express emotion, form close, secure relationships, and explore the environment and learn, all in the context of family, community and cultural expectations of young children.(2)

It can be difficult to acknowledge that the early years sometimes include difficult experiences which if left unaddressed can result in long-lasting developmental harm. Very young children can suffer loss and injury. They can experience depression and anxiety. They can be victims of neglect and abuse. They may be born with neurological or other physical conditions that interfere with physical, social, emotional and cognitive development. Either they or their parents may have issues that contribute to troubled parent-child relationships.

The early months and years are a time of unparalleled and rapid growth and development. It is a time when caregiving relationships are critically important, as the very young child is entirely dependent on the adults around her to meet her physical, social and emotional needs. The unique aspects of counseling for infants relates to the key features of this developmental stage. Very young children are preverbal or have limited language skills. They can experience distress but be unable to articulate the experience. They have just a few ways to tell us that something is wrong. These may include crying, tantruming, sleeping or feeding difficulties, motor control or motor planning problems, or difficulty engaging in mutual interaction, play or affect expression.

Many of these behaviors can be part of typical development, so the diagnostician must be able to distinguish typical from atypical behavior and development. Assessment should include individual observation, parent interview, observation of parent-child interaction, use of standardized assessment instruments and, if possible, observation of the infant in multiple settings. It can take between three and five visits of an hour or more each to develop a diagnosis of an infant or young child. Philosophically it is important to remember that we are diagnosing the child’s disorder, and not the individual. Diagnosis is not meant to label a child but to aid in understanding the best approach to alleviating suffering and restoring healthy functioning.(3)

A lasting impact

It is easy to assume that because babies are “too young to remember” that their very early experiences will have no long-lasting impact. The growing body of research on the brain and on the impact of early adverse experiences tells us differently. Early experiences shape the architecture of our brains and our expectations of the people and the world around us. Babies who experience the death of a parent, maltreatment and subsequent foster placement, or disordered caregiving relationships can experience both short- and long-term developmental consequences.

The good news is that the rapidity of early brain and physical development is on our side. With early intervention and support, it is possible to restore a derailed developmental trajectory to health. There are a variety of approaches to treating infant and early childhood mental health. I think of these at their most basic as approaches to creating an environment in which babies can thrive. This environment includes nurturing, responsive and consistent care, reciprocal interactions, predictable routines, opportunities to play and explore, the meeting of basic health and physical needs, and experiences that challenge and support developmental gains.

Mental health disorders in babies are treated in the context of their primary caregiving relationships, since for babies, these relationships are their world. Parents, whose own childhoods may have included difficult experiences, may need to be helped to develop an empathic understanding of their very young child, to read their cues and to respond in ways that take into account their baby’s interests, needs and temperament. Part of the treatment may include addressing the parents’ own unresolved issues from early childhood or mental health, family violence or substance abuse issues if these are interfering with their ability to respond sensitively to their child. IMH therapists need to be knowledgeable about infant and parent development and mental health needs. Parents can be referred as needed for treatment of medical or mental health conditions that affect their ability to relate to and care for their infants.

Some babies’ cues are harder to read than others. They may have neurological, developmental or motoric difficulties that make it hard for them to communicate. A major difference in parent’s and child’s temperament can cause relationship distress. A baby may be born into a very stressful time in a family’s life or be very different from the baby the parent had imagined and hoped for. A parent experiencing depression may have difficulty tuning into and responding to his or her baby. These and other factors can cause distress in parent-child relationships. It is not developmentally possible for babies to adapt to their parents’ temperament, alleviate environmental stressors or immediately overcome developmental delay or other physical condition. Parents, however, can be helped to “tune in” their baby, recognize his cues, understand and adapt to his temperament. They can also be supported in exploring their expectations, adjusting to the reality of their child, and helped directly or through referral to cope with stressors impacting the family.

Depending on what appears to be the cause or causes of a baby’s mental health difficulties, treatment approaches can address issues that appear to originate within the child and may also involve the internal response to external events, those that stem from distressed parent-child relationships and those exacerbated by stressful life conditions. Treatment often needs to be multidisciplinary, engaging physical, occupational and mental health therapy. The family may need other services as well, including help meeting the family’s concrete needs or help with issues such as domestic violence or substance abuse.

Assessing and diagnosing infant mental health disorders requires a solid understanding of typical behavior and development and of parent-child relationships, acute observation skills and the ability to integrate diverse sources of information. It takes time as well. At least three clinical visits and preferably five are needed to develop an initial diagnosis.

As culture powerfully influences expectations for children, practitioners must understand families’ cultural expectations for children. In the U.S. the mainstream culture emphasizes independence. In many Asian, South American and Native American cultures, interdependence is emphasized. These different cultural expectations lead to different parenting practices and expectations of children and should not be seen as dysfunctional.

For example, a parent whose culture emphasizes interdependence may spoon-feed a child who is 3,4 or 5 years old. A parent who participates in mainstream U.S. culture is more likely to encourage her child to try self-feeding as young as 6 or 7 months of age. According to their cultural context, both parents are “right.” Neither the self-feeding 7-month-old nor the 4-year-old who allows her parent to feed her is necessarily showing signs of developmental difficulty.(4) Both children are experiencing support for their healthy development.

Finding support

Working closely with babies and their families is taxing, challenging professionals’ intellectual, emotional and physical resources. The capacity to work effectively with families is built and sustained within a network of supportive collegial relationships. Relationship-based practice deliberately makes use of the power of relationships to support learning, growth and development.

When relationships among colleagues are characterized by trust, respect, professionalism, commitment to growth and sharing of power, the workplace climate supports reflective practice. Reflective practice involves thinking deeply and carefully about the work and can be considered reflection for action (preparation for what will happen) and reflection on action (reviewing what happened). Reflection in action, perhaps the most difficult, is honed by repeated experiences reflecting for and on action. Reflection in action is the apparently seamless response a practitioner provides in the moment, rapidly integrating knowledge and feeling, cognition and emotion, self-awareness and empathic understanding.

Reflective supervision is a formalized, regular opportunity for each staff member working closely with families to have the regular opportunity to join with an experienced supervisor to reflect for and on action. A safe, mutual, respectful supervisor-staff relationship encourages the open exploration of experiences, their impact and options for the ongoing work with families. Through the parallel process in relationships, such experiences for counselors will help them to encourage parents to establish nurturing and supportive relationships with their young children. Counselors and other professionals working closely with families and young children will find the quality of their work enhanced through relationship-based and reflective workplaces.

  1. This idea and the science of early childhood are discussed in From Neurons to Neighborhoods: The Science of Early Childhood Development, published in 2000 by the National Research Council Institute of Medicine.
  2. This definition appears in the 2002 ZERO TO THREE publication, Building Strong Foundations.
  3. The diagnosis of infants and toddlers and classification of early mental health disorders is discussed in ZERO TO THREE’s 2005 manual Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood: Revised.
  4. Of course it is possible that a parent would feed a child due to developmental difficulty that makes self-feeding difficult. This speaks to the care with which observations must be interpreted!

Resources
To learn more about early development and infant mental health, counselors can visit:

ZERO TO THREE
www.zerotothree.org

World Association for Infant Mental Health
www.waimh.org

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