Tag Archives: Children & Adolescents

Counselors and the clinical staging model

By Allen E. Ivey and Mary Bradford Ivey February 28, 2014

sad-teenCounseling is a preventive profession, typically working with issues and challenges that our clients face daily. However, client concerns often exist at deeper levels, and counseling process often shades into therapy. As counselors, you regularly encounter children and youth who may be at risk. Whether with a medicated child who has been deemed as having attention-deficit/hyperactivity disorder or a depressed teenager whose family is unable to afford private treatment, counselors often end up being the key mental health resource. Of necessity, we often work with clients who have no other realistic source of treatment. For example, a teenager may return to high school after a stay in a psychiatric or drug treatment facility. A child or adult may need specialized care, but no referral sources are available.

The impact and effect of your work is vital not only with the “normal” issues that young people face, but also with the issues posed by potentially more disturbed youth. The National Institute of Mental Health estimates that 26 percent of the U.S. population ages 18 and older has a diagnosable mental disorder during any given year, while 6 percent face diagnosis of serious mental illness. Sixty-five percent of serious mental conditions such as anxiety and affective disorders appear before age 21, thus emphasizing the importance of early counseling intervention. Children and adolescents are increasingly being diagnosed with mental disorders and prescribed medications that can sometimes be dangerous. In 2012, the website ScienceDaily reported a 62 percent increase in the use of antipsychotic drugs with publicly insured children, with two-thirds of these potentially dangerous drugs being off-label prescriptions. In 2010, the Archives of General Psychiatry reported evidence that these medications shrink the amount of gray matter in children.

Professor Patrick McGorry, an Australian psychiatrist and world expert on young people at risk for psychosis, is challenging the very concept of diagnosis for conditions such as borderline personality disorder, major depression and schizophrenia. He asserts that the diagnostic categories in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) are “endpoints” with little or no attention paid to etiology and developmental issues. For example, subclinical youth may show signs of decreased functioning. Although we may see affective dysregulation and other signs, clear diagnosis is usually impossible. “Persistence and severity are key dimensions setting the bar for care, irrespective of the specific set of features,” McGorry has said. He speaks of a “soft entry” to treatment rather than arbitrary categories that all too often lead to overmedication and overtreatment.

McGorry Clinical Staging Table

Table adapted from “Early intervention, clinical staging in youth mental health” as presented by Patrick McGorry (see youtube.com/watch?v=gYTX7lQU_Ag for a full presentation of the model in its most current form).

CLICK HERE TO VIEW PDF IN FULL SIZE: McGorry Clinical Staging Table


McGorry makes it clear that all “disorders” have early clinical features or prodromes — early symptoms that might indicate the onset of a disease. Prodrome is the term ascribed to at-risk youth whose functioning is decreasing significantly. It has been found that one-third or more of these youth will become psychotic within three years. However, it is important to separate those youth who have a true prodrome from those who may be suffering from grief or trauma, the major effects of which pass over time.

The research appendix of the DSM-5 names the prodrome as attenuated psychosis syndrome. There is evidence that preventive treatment programs can significantly reduce later reversion to psychosis. Rather than one-third of these youth becoming psychotic, a 2012 review written by McGorry and colleagues in the journal Clinical Practice found that early intervention preventive programs reduce that figure to 5 to 10 percent. Even if psychosis does not appear, however, those considered at risk continue to have significant life challenges, often requiring some form of counseling throughout the life span.

This is an important issue, and the question remains — how can we work effectively to prevent psychosis in young people? In hopes of finding the answer, we visited Australia to meet McGorry. There we saw programs in operation that make a significant difference in preventing serious disturbance in youth. Rather than applying the potentially damaging label of attenuated psychosis syndrome to these youth, McGorry uses the terms high risk and ultra high risk. His program focuses on early prevention and avoids medication as much as possible. He worries that the attenuated psychosis syndrome label being used in the United States will lead to overuse of unnecessary medications because psychiatry does not give much attention to prevention or early intervention. If the attenuated psychosis syndrome diagnosis as formulated in the DSM-5 is accepted in isolation, we can expect preventive research to be ignored, while seeing a vast increase in potentially dangerous medications for youth.

A practical framework 

Counselors often are the first professionals to observe when a young person’s behaviors indicate high risk of continuing and future major behavioral and emotional issues. Thankfully, effective counseling and systematic programs can make a difference, and the need for further help, or even institutionalization, may be prevented.

Diagnostic risk factors include, first of all, a noticeable decrease in functioning. The endpoint features of attenuated psychosis syndrome in the DSM-5 include symptoms that may appear only occasionally; most of the time, these youth will function normally in society. The attenuated psychosis syndrome diagnosis looks for odd beliefs or magical thinking, perceptual disturbance or some paranoid ideation, along with occasional disconnections from reality. Depression, anxiety or explosive outbursts may increase. The youth’s appearance may change in terms of clothing, self-care or significant gain/loss of weight.

McGorry’s clinical staging model is designed to work for patients, clinicians, families and researchers. It is rooted in the model of normalization and prevention. Clinical staging is the method used in McGorry’s Early Psychosis Prevention and Intervention Centre (EPPIC), which focuses on youth at risk with specific recommendations for treatment at each clinical level (see the accompanying table). The diagnosis is for level of need and treatment, not for a specific category.

Clients are first placed in two general categories — those who appear to be working with “normal” difficulties and those who may be at risk, high risk or even ultra high risk for becoming constantly depressed, bipolar or schizophrenic. Typically, the first group represents Clinical Stages 0 and 1. This group is treated using concepts that are well known and integral to the counseling movement. It is here that we see the counseling profession overlapping with in-depth psychiatry. Furthermore, it is obvious that counselors have an important role in working with at-risk youth. While traditional diagnostic endpoints do not lead to treatment recommendations, clinical staging does. The scaling and normalization of youth concerns leads to a newly integrated form of counseling and therapy.

McGorry’s original research has been replicated in many settings, internationally and in the United States. There is clear short- and long-term evidence that the clinical staging framework (or variations on that theme) reduces the chances of youth reverting to psychosis. Those youth who may never revert to psychosis receive the benefit of quality treatment without being labeled as suffering from attenuated psychosis syndrome.

Why are counselors so important in this process? Take a look at the mental health workforce in the United States. The Occupational Outlook Handbook shows more than 1 million helping professionals but lists only 24,210 psychiatrists, although other estimates range as high as 36,000. Even if we take the larger figure, psychiatry represents approximately 3.6 percent of professionals able to meet the mental health needs of the nation. From these data, it is patently clear that members of the American Counseling Association will continue to play a major role. The primary and secondary treatment options listed in the accompanying table have long been considered major roles. Not only are counselors needed, but they have the skills and experience to work with these youth.

Coordination of mental health services is key to the EPPIC model — infants, children, adolescents and adults in individual, family, group, school and community contexts. Furthermore, all mental health issues, from typical daily concerns to serious issues such as autism and schizophrenia, fall within this framework. McGorry seeks to avoid the use of medications with clients as much as possible, while focusing on psychoeducation and cognitive behavior therapy. The model includes typical counseling interventions such as stress management, anger management, family counseling and job placement with support, all with an extensive emphasis on relapse prevention.

The clinical staging model in a high school 

The counseling and guidance program at Massachusetts Wellesley High School illustrates how the clinical staging model is related to counseling practice. Under the leadership of principal Andrew Keough, Wellesley High School states that “schools are more like families than like business, and every member needs a voice.” To build that family community, students have brief daily meetings and a half-hour meeting once per month in advisory groups of eight to 10 members. This ensures that every teen has personal contact with a teacher, counselor or administrator. Groups are randomly chosen to enlarge the students’ circle of acquaintance in the large school. There is a daily check-in, typically followed by short discussions on topics such as “what was the highlight of the weekend” or a school issue. There is often enough time for brief trivia contests or discussion of personal issues as well.

Additional student contact is made twice weekly through small group guidance seminars taught by counseling staff. The small groups are limited to 12 to 15 students and take place for all four years of the students’ high school experience. Groups in the first year cover study skills and school adjustment issues. In ensuing years, the groups tackle decision-making skills, positive mental health and symptoms of anxiety and depression. These programs make it possible to know all of the school’s students, and they also encourage self-referrals to counseling staff. They are important components of the first two clinical stages of McGorry’s model. Counseling, of course, covers the full range of academic and personal issues, including the ability to support students who are more challenged.

A student support team meets weekly to discuss student issues, with special attention paid to Stages 2 and 3, but always with awareness of Stage 1. For students at Clinical Stage 3 who are more distressed and may have been released from a hospital or drug treatment program, small groups ranging from three to five people provide support, while the leader often works in concert with the treatment facility. These groups also serve as transition teams to gradually return these students to their regular classrooms.

Another preventive effort designed to further community is an after-school enrichment/recreation program that caters primarily (but not exclusively) to students who are not involved in the many formal school groups or athletic teams. Students are encouraged to define their own desires for a group experience, supported by an interested teacher. Examples include time in the gym or on the athletic field for those who did not make school teams, a computer group that is taught how to develop apps, karate and boxing groups, clay and art workshops, and many others.

Somewhat parallel to the Wellesley program, McGorry has originated the Headspace program, which seeks to work with youth when “things are not quite right.” These centers offer similar services to those provided by Wellesley, but in a separate setting. There are currently 45 Headspace centers throughout Australia, with 90 planned by 2015. They function as combination community centers with a counseling focus for young people. Supportive counseling is available, and a major effort is made to get parents involved. Headspace emphasizes positive mental health and therapeutic lifestyle changes such as exercise, socialization skills, meditation and relaxation, drug prevention, adequate sleep and nutrition as personally and multiculturally appropriate. Headspace also includes access to medical and psychotherapy services and interface with crisis teams (24/7 mental health teams). The central function of these programs is to enable at-risk youth to stay in the community, to prevent more serious issues and to provide counseling support as appropriate.


Visit the EPPIC website at eppic.org.au or the Orygen Youth Health website at oyh.org.au for additional information, including the outpatient programs where methods, systems and practices can be downloaded. We also recommend EPPIC’s 2010 Cognitive-Behavioural Case Management in Early Psychosis: A Handbook (oyh.org.au/online-store/cognitive-behavioural-case-management-early-psychosis-handbook). Extensive information on Headspace can be found by conducting a Google search. In addition, many useful videos are available, often presenting real clients and counselors discussing matters such as bullying, depression and gay/lesbian issues. These can be found on youtube.com/playlist?list=PL8C639D508E0A4B3C  or by searching Headspace Ambassadors on YouTube. Information on Wellesley High School is available at wellesley.k12.ma.us/wellesley-high-school.



Allen E. Ivey is distinguished university professor emeritus at the University of Massachusetts, Amherst and courtesy professor at the University of South Florida. Contact him at allenivey@gmail.com.


Mary Bradford Ivey is a courtesy professor at the University of South Florida. Contact her at mary.b.ivey6@gmail.com.


Letters to the editor: ct@counseling.org


Working with sexually abused children

Gregory K. Moffatt November 25, 2013

BearMateo (not his real name) sat on the floor in my office playroom. Each week in therapy, he routinely played with a small plastic doll and every time, without fail, he placed objects in the doll’s mouth. This day, however, he did something more aggressive. His eyes wide and his face full of rage, he took a Tinker Toy, an apparent phallic symbol, and repeatedly jammed it into the doll’s mouth. “He doesn’t want it in his mouth,” Mateo said into the air, “but he’s going to get it in there anyway!”

A male babysitter had sexually violated Mateo several months earlier. I’m confident, in part based on Mateo’s playroom behavior, that the babysitter had forced himself into Mateo’s mouth. Fellatio wasn’t the only violation forced upon Mateo, but it was the most brutal. Recovery for Mateo would take months.

Those sessions occurred more than 25 years ago. Mateo was one of the first seriously abused children to enter my private practice, and I’ve never forgotten him. Unfortunately, he represents only one in a very long line of abused children I have seen over a nearly three-decade career. In some ways, each child is different, responds to abuse differently and progresses at her or his own pace, but the stages of counseling with this population generally are predictable.

Stages of therapy with abused children 

Stage one: Trust. No matter how much parents tell me their children are shy or “won’t talk to a therapist,” I’ve never failed to gain these children’s trust within the first session or two, often within the first few minutes. More than once I’ve been shocked at how quickly children have divulged deeply hurtful and frightening information to me, almost as though it was ready to explode from them at the first opportunity that someone took to listen. Other times, however, it has not been so easy. Hundreds of children have come through my office doors, and I have learned to use the tools of my trade to create an environment of safety.

Play therapists have an advantage over more traditional counselors in these first visits. My office is full of toys, puppets, books, crayons and sandboxes, along with literally thousands of miniatures. As we begin, my first question is usually “Would you like to play for a while?” Only rarely have I come across a child who didn’t want to play.

I want to give the child as much control as possible throughout therapy, but it is especially important during these first sessions. A therapist I greatly respect taught me the phrase, “You can do about anything you want to in here. If there is something you can’t do, I’ll tell you.” I have used that opening line for years, and it has never failed me.

But children will test that statement. When I said this during Mateo’s first visit, he asked skeptically, “Can I dump all the toys out of the toy box?” He rested his hand on the rim of the large plastic tub that contained many of my toys.

“If you need to,” was my response. As I have learned to expect when such a question is posed, Mateo turned the box up on end and dumped everything out. I sat quietly and smiled at him. He smiled back. I had passed his first test for me.

Mateo called me Greg from our first session. I hadn’t earned my Ph.D. at the time, but even now, I don’t like children referring to me as “doctor.” That term is too easily equated with shots or unpleasant experiences. “Greg” is just fine with me when parents will allow it. That also helps begin to create a context of “us” rather than a view that the child is there to be “treated.”

I have to be very careful how I move when I’m with children such as Mateo. Sexually abused children do not interpret movement in the same way that other children do, especially when that abuse has been repeated over many weeks or months. What most children would regard as an innocuous touch may easily be interpreted by sexually abused children as an invitation or command for sex. In the case of physically abused children, they will flinch if I move too quickly to reach for my pen, scratch my ear or adjust my sitting position on the floor (something I have to do often as I get older). Flinching is an unconscious protective reaction that these children have learned. The quick fists of abusers have surprised them before, so these children learn to be vigilant for punches and backhands. The body remembers.

Stage two: Symptom reduction. Once I’ve built trust with the child, I can begin stage two. During this part of therapy, I want to accomplish two things. First, I want to reduce the negative symptoms that brought the child to my office in the first place. If he or she isn’t sleeping or eating, or is having trouble paying attention at school or getting along with siblings, I work with the child and guardian(s) to address these symptoms.

Mateo regularly acted out sexually. He masturbated in public. He exposed himself to other children on his school bus and in his classroom. Most troubling, he forcibly fondled other children, especially younger girls who were too small or too confused to say no. We had to address these behaviors immediately. I almost always use behavioral modification tools to intervene when behaviors are as serious as these.

The second thing I want to accomplish is to provide the child with skills to manage or prevent his or her issues. I worked with Mateo to recognize his urges and to develop ways to manage them. I have two recliners in my office — one adult sized and one child sized. These are the “thinking chairs.” Mateo and I sat in the thinking chairs, both of us staring at the ceiling.

“I’m wondering what we could do when our body parts feel funny,” I said, referring to the urge to masturbate.

“Maybe I could go to my room,” Mateo said, interestingly turning my use of “we” into “I.” Children are surprisingly intuitive and insightful when adults take the time to listen to them. Going to his room was a good idea — one of many that Mateo came up with during the course of our therapy. When the child discovers a solution, he or she is more likely to believe it will work and, hence, more likely to implement it.

Stage three: Facing demons. Abreaction is a term I learned from Lenore Terr, a writer and psychiatrist in San Francisco. Abreaction means that the child is reliving or replaying the abuse in therapy. We all do this in everyday life. When something significant happens to us, we have the need to talk about it —reliving it through conversation.

Imagine that you saw a car accident happen in front of you on the way to work. You would tell your workmates when you arrived. You would think about it during the day. You might call your spouse and relate the event. This would go on until you had “talked it out.”

Young children don’t have the vocabulary or cognitive ability to talk it out. Instead, they act it out in dramatic play, through the pictures they draw or in the activities they engage in in my sandbox. They literally replay their traumas.

When Mateo was forcing the Tinker Toy into the doll’s mouth, he was abreacting. He was abreacting when he fondled children on his school bus, and his masturbation was also a form of abreaction. Like an interested workmate or an understanding spouse listening to your story of the auto accident, I help children work through their stories over and over until they achieve a resolution.

One child in therapy with me abreacted to a perpetrator by repeatedly burying a little toy man in a wad of play dough each day that we worked together. In subsequent sessions, the child left more and more of the little man uncovered by the play dough. By our last session together, only the toy’s feet remained covered. “I see the man is almost free,” I said to the child. Confidently, the child smiled at me and said, “That’s OK, I can handle him.” This little boy had worked through the trauma of his abduction and abuse. His therapy was almost done.

Stage four: Wrapping up. Once symptoms have abated to a point where the child can cope, when he has the tools to deal with stressors in his life and the invasive thoughts and dreams that haunted him have faded away, the child is ready to work toward closure.

After 10 months of therapy, Mateo’s parents reported to me that his autoerotic behavior was under control and he rarely engaged in that behavior in environments where it was inappropriate. He was no longer exposing himself or talking sexually with other children, and he hadn’t touched another child since our first visit. His abreaction in therapy had trickled into almost nothing. His outbursts and temper tantrums were greatly reduced, and his parents now had the skills they needed to work with Mateo without my assistance. It was time to talk about closure.

Stage five: Termination. Saying goodbye to Mateo was hard for me. When growth happens as it should in therapy, it is rewarding and exciting. It is hard not to take ownership of it, but the truth is, Mateo was responsible for that growth, not me.

In the last session with each of the children I work with, the child gets to choose what we do. This allows the child to have control of his or her final hour with me and the work we have done together.

Mateo selected what many children subsequent to him have chosen. “I want to draw something,” he said.

I nodded but otherwise said nothing. Spilling crayons onto the floor in front of him, he worked intently, drawing on the paper while I watched. I was afraid to move because I didn’t want to break his concentration. When he finished, he took a deep breath, smiled at me and handed me his drawing. Two stick figures were holding hands, the sun bright in the upper part of the page and flowers standing like sentinels on either side of them. One figure looked like Mateo, who always drew himself wearing a baseball cap. The other figure was an adult.

“Tell me about your picture,” I said with interest. But I already knew what he was going to say. It was just what I had hoped for.

“This is me,” he said, pointing to the smaller figure with the ball cap. Then, pointing to the other figure, he added, “… and this is my mom.”

He was ready to go. There would be days in the future when Mateo’s abuse would still haunt him, but for now, he had worked through his abuse, his support system was in place, and it was time for me to say goodbye.


Kids like Mateo are the reason I chose counseling with children as my career path. During my residency and internships, I sat with adults, many of them in their 50s and 60s, while they shared unresolved traumas dating back to childhood. I thought it was tragic that decades earlier, they had been set on a path that permanently affected their lives. Those traumas had set a course for the careers they would choose, the people they would marry and how they would cope with life.

For almost all of these individuals, no one had been there to help them at the time of their trauma. If they had received intervention those many years earlier, their lives would have turned out very differently. My hope for children like Mateo is that the time they spend with me will address issues that, left untreated, could lead to years of dysfunctional relationships and unhealthy habits.

There is nothing more satisfying than working with a child like Mateo. Boys and girls bring their stories to me day after day. The first time they come into my office, they are often broken and fragmented. They sometimes stare at me with wide eyes, wondering if it is even possible to overcome the painful experiences that life has dealt them. Yet at the same time, they are very hopeful and willing to take a chance on me. Most of them leave as completely new creatures. Even though their experiences will always remain with them, I can have confidence that they will not be in a counselor’s office 40 years in the future, crying because of the abuse they suffered. That is something we can take care of now, and that is why each day I face the challenges of this population with courage and hope.

Click here to read Gregory K. Moffatt’s related article on complications related to working with sexually abused children. In the article, he discusses confidentiality and mandated reporting, hidden agendas, assessment versus therapy, evidence-based therapy, preparing for court and staying healthy as a counselor when working with this population.



Gregory K. Moffatt is a licensed professional counselor and professor of counseling and human services at Point University in Georgia. Contact him at Greg.Moffatt@point.edu.

Letters to the editor: ct@counseling.org




Complications when working with sexually abused children

Gregory K. Moffatt November 21, 2013

sexually-abused-childrenWorking with children who have been sexually abused has taught me many things. While some children progress very quickly, I have learned to have patience with the children whose recovery comes more slowly. I’ve learned to be careful in taking notes, how to spot parents or guardians who are trying to manipulate me, and how to prepare for court. Working with physically and sexually abused children isn’t easy. There are many things about therapy with this population that I wish I’d been taught in graduate school, but instead I had to learn through experience.

Confidentiality and mandated reporting

Fortunately for me, Mateo’s perpetrator had already been arrested and child protective services had been involved before Mateo came to see me. But limits of confidentiality due to mandated reporting still remained. My records still could have been subpoenaed and I could have been called to court. I had to be very careful.

I make the limits of confidentiality clear to my clients’ parents and guardians, but it is challenging to help the child understand mandated reporting, court-ordered disclosure or similar issues that would require me to talk about his or her personal issues with others. Further complicating this puzzle is the inclusion of guardians ad litem and social workers to whom I occasionally must also report. Yet it is imperative for the child to understand that I cannot always keep his or her secrets. When I see that a child is about to disclose something I might have to share with someone else, I often have to remind the child about my obligations. “Remember I told you that sometimes I have to tell people what you tell me?” I remind the child. “I think you might be about to tell me something like that, so I wanted to remind you so you could choose whether or not you want to say it.”

Even when I don’t have to worry about disclosing issues to the court or to child protective services, I still must contend with the many people in the child’s life who want to know what is going on in therapy. Mateo’s biological mother routinely brought him to therapy, but a grandmother, an aunt and his father also occasionally brought him in. Access to a child’s records/therapy progress legally and ethically belongs to the custodial parent or parents, but this can be a challenging dilemma. Grandparents, stepparents, siblings, stepsiblings, live-in girlfriends or boyfriends, and even neighbors are among the people who have brought children to my clinical office or who have called and requested information about a session.

It can be challenging to maintain confidentiality for the child while partnering with parents, guardians or caregivers. I want and need parental cooperation, but I am also bound by ethics and by the law regarding what I can say to whom. One child I saw off and on for almost a decade was not in the legal custody of his grandparents for most of that time, even though the child had lived with them since birth and his mother was almost completely absent from his life. So, should I have taken the grandparents’ payment but refused to discuss therapy with them? I don’t think so.

Hidden agendas

Working with abused children is complicated enough by itself. We have to consider developmental issues at the time of the trauma, who the perpetrator was, whether it was a single event or ritualistic abuse, the health of the child’s support system/family, and the coping skills and problem-solving set the child has at his or her disposal. But that isn’t all we have to think about as therapists.

Parents, especially those who are divorcing or battling for custody, often have hidden agendas when they bring their children to me. “I hope my husband didn’t do anything to my daughter,” I’ve often heard, “but I’m worried that he might have abused her.” Sometimes this statement comes from parents who legitimately do have this concern. Other times, the parent is attempting to play me, hoping I’ll find something that might imply abuse so that he or she can use that information against the spouse in a custody hearing. On occasion, the parent’s sole purpose was to have the accusation/intervention on record for when she or he took a custody request to a judge. My intake forms specifically ask about marital status, and I am very cautious when divorcing parents bring “concerns” of potential abuse that just happened to pop up after a decision to divorce.

Assessment versus therapy

As a young therapist, it took me awhile to realize there was a difference between assessment and therapy. In those days, I approached all children the same. I was originally trained as a person-centered therapist, and I had very little preparation in my graduate work in assessment. I was taught that what happened outside my office didn’t concern me. My job was to help the child achieve healing, so I began therapy with the first session. Imagine my embarrassment the first time I encountered the court system without a clear assessment.

The assessment is the first step in determining, as a mandated reporter, if I need to call child protective services. I have to address all evidence that points toward abuse. I have to address all evidence that points away from it as well. If I am called into court, I can be certain a competent attorney will leave no stone unturned to exonerate his or her client. Likewise, I don’t want an innocent person going to jail because I didn’t do a thorough assessment.

If a case has already entered the court system or been adjudicated, as was true for Mateo, I can relax a little and move more quickly into therapy, but assessment is still important. I have to address developmental issues. Understanding the child’s social, physical, emotional and cognitive development plays a key role in interpreting the child’s behavior. A symptom that may suggest sexual abuse at one developmental age may not be an indicator at another and vice versa. For example, very young children rarely make up stories about sexual abuse. They may be coached into saying things that imply sexual abuse, but they almost never spontaneously make up explicit stories of sexual maltreatment. On the other hand, prepubescent or pubescent children might. They have the cognitive ability to know about sex and its meanings and to use such skills to deliberately hurt a foster parent, guardian or parent. Developmental age, coping strategies and problem-solving abilities have to be noted before I can set forth an appropriate treatment plan.

Evidence-based therapy

In the early 1980s, nobody talked about evidence-based theory. It was assumed that if one was good enough to be recognized by the court as an expert witness, one must know what he or she was talking about. No more.

Whether I am assessing a child or doing therapy, the processes have to be based on something other than “I think it works.” I resisted this transition at first. After all, I’d worked with hundreds of children. Hadn’t I seen their progress?

But now I understand much better the importance of evidence-based approaches. Whether I am assessing the child or engaging in therapy, it is my responsibility to use approaches that are shown to be valid rather than simply doing what feels right to me. Not only is this more defensible in court, it is also the ethically appropriate thing to do.

Preparing for court

When I began working with children shortly after completing graduate studies, it was believed that court testimony could further traumatize a child. Therapists, lawyers and judges alike worked hard to avoid having the child appear in the courtroom. But research, as well as my own experience, has proved those ideas to be flawed.

Court can be traumatizing, but more often than not, children are empowered by the opportunity to go to court. They can fearlessly sit in a witness box, testify in their own childlike language and leave the courtroom feeling as though they have taken control of their lives. Defense attorneys are reluctant to badger young children, and their testimonies can be powerful. Therapeutically, it is equally powerful when a child faces his perpetrator and comes away knowing the perpetrator is going to jail.

Preparing a child for court often involves setting up my office as a courtroom. Children usually know nothing of judges, juries, court recorders or attorneys, so we practice playing court in different roles. This role-playing teaches the child what to expect and demystifies the courtroom. I often work with the child’s attorney as we prepare for court. I cannot prepare the child’s answers to likely questions, but I can prepare the child for the questions he or she might expect. “Just tell the truth and answer the questions,” I routinely say. “You are not in trouble, but the judge needs to hear from you.”

Prior to court, case notes need to be reviewed. Anything that will be used in depositions or provided to the court needs to be clear, concise and in objective, clinical language. I generally avoid writing down anything that isn’t necessary because if it isn’t written down, it cannot be subpoenaed. For my own testimony in court or depositions, one rule I live by comes from that old line in Dragnet — “Just the facts.” While I have my own agenda and hopes for the outcome of trial, the courtroom is no place for grandstanding, soapboxes or emotion. I answer questions as concisely as I can, I don’t speculate, and I never volunteer information. Even though it sometimes fails, I trust the legal system to do its job, and I do mine.

Staying healthy when working with sexually abused children

The hardest part of working with abused children, at least for me, is not the sad stories. I’ve heard them a thousand times, and a precious little face is attached to each story. It would seem that this work would eventually take its toll. But rather than wearing me down, working with these children is empowering for me. I am helping to make their lives better. I also cope with working with traumatized children by helping to empower them. I teach them skills they need to survive their troubled lives. I help them find ways to solve their problems, and I help their parents work with them more effectively.

What is hardest for me is when I am totally defeated by the court, social services or the parents of the children I work with. When I’ve exhausted all of my resources and cannot do more, I am most discouraged. At times like these, I simply have to remember the sad truth that I cannot save everyone.

To help the children in my practice, I have to take care of myself. It is imperative to maintain a good diet, exercise regularly and get enough rest. I cannot be what these children need me to be if I am tired, lethargic or burned-out. I find plenty of time to play and to disengage from life at the office. I take care of my health, I find time to laugh and refocus on the “normal” world, and I don’t let myself become jaded. I recognize that there are thousands of wonderful parents in the world. I can separate myself from my work because I’ve learned to put my work into compartments that I can open and close at will.

I have resisted texting, giving out my personal cell phone number and engaging in social media. I have to disengage from people with some regularity or I can’t rest. When I am at home watching a movie or reading a book, I am fully at home. I am not like many of my colleagues who feel the need to check email every five minutes or look at every text message that chimes in, no matter what activity, meal or conversation it might interrupt. Our culture has made almost any trivial communication an emergency that demands immediate attention. Emergencies happen, but they are relatively rare. When real emergencies happen, I am accessible, but otherwise, my time away from the office is for me and my family.


For more on this topic, read Gregory K. Moffatt’s companion article, “Working with sexually abused children,” which appears in the December issue of Counseling Today.

Gregory K. Moffatt is a licensed professional counselor and professor of counseling and human services at Point University in Georgia. Contact him at Greg.Moffatt@point.edu.

DBT: An introduction and application with adolescents

Karen Michelle Hunnicutt Hollenbaug March 1, 2013

BPD_2_27019866Marsha Linehan developed dialectical behavior therapy (DBT) in the early 1990s specifically for the treatment of borderline personality disorder. DBT is a multifaceted treatment approach that includes facets of cognitive behavior skills training, mindfulness meditation, behaviorism and dialectics. Though none of these individual aspects is novel on its own, implementing them together in a structured program was an innovative development that has led to greater client success.

DBT is structured to help clients gain insight and skills to manage their thoughts, emotions and behaviors. Per Linehan’s guidelines, the format is intensive, involving a two-hour weekly psychoeducational skills group, one hour of individual therapy each week, weekly skills homework and phone coaching between sessions. The therapy focuses on four skills modules:

  • Mindfulness: Teaches mindfulness meditation
  • Emotion regulation: Educates clients on emotions and how to manage them
  • Interpersonal effectiveness: Teaches skills to help clients manage healthy relationships
  • Distress tolerance: Teaches skills to help clients deal with emotional crises

Therapists engage the client dialectically, working to incorporate interventions to validate the client while facilitating client change. Linehan dialectically posits that clients are doing the best they can but also need to do better. Therapists also use behavioral interventions to reinforce the use of new skills and positive coping, while working not to reinforce old, maladaptive ways of coping.

Adaptations for adolescents

After several randomized, controlled trials proved DBT’s effectiveness in decreasing symptoms related to borderline personality disorder, studies have been conducted with several other populations and diagnoses, including substance dependence, eating disorders and mood disorders.

Preliminary research suggests DBT also can be effective in treating adolescents, likely because many adolescents struggle with symptoms that mirror those found with borderline personality disorder, including nonsuicidal self-injury, suicide attempts, dichotomous thinking, impulsive behaviors, labile moods and unstable interpersonal relationships. Current research shows that among adolescents, those struggling with these symptoms, including adolescents who have been diagnosed with an Axis I disorder, have a previous history of noncompliance in treatment and have significant difficulties regulating their emotions, will benefit most from a DBT program.

In their 2007 book Dialectical Behavior Therapy With Suicidal Adolescents, Alec L. Miller, Jill H. Rathus and Linehan developed several adaptations to traditional DBT for use with adolescents. Although the involvement of the support system is important when using DBT with adults, the involvement of parents and guardians when working with adolescents is even more important. When parents learn the skills their children are learning, parents can model these skills at home and also use the skills to facilitate their own coping. Family involvement can also be an important aspect of treatment compliance. Optimally, therapists will offer skills training groups for family members, either in conjunction with the adolescent’s skills training, separately or some combination of both. In addition, individual family therapy can be implemented as needed, as can between-session phone coaching for the parents as well as the adolescent. At the very least, support from family members is crucial to DBT’s effectiveness with adolescents.

Miller, Rathus and Linehan also included the addition of a fifth module, “Walking the Middle Path.” This module teaches the concept of adolescents and their parents thinking and acting dialectically, as opposed to thinking and behaving in extremes. The module includes common “dialectical dilemmas” — for example, when parents and adolescents vacillate between being too strict or too lenient with expectations and boundaries. Another aspect involved in this module is validation — specifically, teaching adolescents and parents how to validate their own thoughts and feelings as well as the thoughts and feelings of others.

When implementing DBT into any setting, regardless of the population, clinicians need to consider whether it would be best to implement full DBT or an adaptation of DBT. For example, many clinicians introduce only the psychoeducational skills group if limitations may keep them from implementing individual DBT treatment or the phone-coaching element. Studies have tracked the use of DBT in various settings, including inpatient units, outpatient settings, intensive outpatient programs and schools. Adaptations are often needed to fit the time frame and population involved at each site, however. If clinicians decide to implement only the DBT skills groups for adolescents, Miller, Rathus and Linehan suggest keeping the groups as homogeneous as possible, taking into consideration age, diagnosis, symptoms and gender. In addition, it may be best to exclude clients struggling with psychosis, mania, developmental disabilities and severe substance abuse from these skills groups. These are suggestions, however, and published studies have detailed the use of DBT with clients with developmental disabilities, substance dependence and other severe disorders.

Specific DBT skills 

Many DBT skills can be implemented easily into current treatment approaches and programming with adolescents. I will give a brief overview of a select few, but these skills — as well as several others — are covered in more depth in the resources listed at the end of this article. Many of these resources include handouts and homework assignments for clinicians to use in treatment.


One of the main facets of DBT is mindfulness. In DBT, mindfulness is used so clients can activate their “wise mind” — the dialectic between their emotional mind (when all thoughts and behaviors are controlled by emotions) and their reasonable mind (the thinking, logical side). The wise mind is often considered intuition, and activating the wise mind via mindfulness is the key to effective decision-making.

Mindfulness is not necessarily limited to sitting quietly and controlling one’s thoughts. Any activity can be considered mindful as long as the client is in the moment, observing, describing and participating — mindfully, nonjudgmentally and effectively. Some nontraditional DBT group mindfulness activities include singing “Row, Row, Row Your Boat” in a round while performing hand movements, engaging in a silent exercise in which one partner mirrors the other partner’s movements exactly, or putting a dab of toothpaste on one’s nose and being mindful of the experience.

It may be difficult to engage adolescents with certain mindfulness activities in a group setting, especially in the beginning or when one or two group members balk at the idea of doing something that might make them look silly in front of their peers. In such instances, I encourage group members to be mindful of the thoughts and emotions they are experiencing in that moment that make them reluctant to engage in the activity. This exercise often elicits further discussion.

For practice outside of the group, I suggest that clients engage in mindfulness activities while doing the dishes, driving or washing their hair. As long as they are in the moment and focusing on that one activity, they are engaging in mindfulness.


Another skill that can be particularly helpful for adolescents is the use of an acronym, DEAR MAN, taught in the interpersonal effectiveness module. Adolescents can put this skill to use when they wish to ask for something they want or when they need to say “no.”

The acronym is as follows: Describe the facts of the situation; Express your feelings and opinions surrounding the situation; Assert what you want; and Reinforce to the other person why this will be helpful to both parties or to the relationship. Clients will do this by staying Mindful and ignoring any verbal attacks; Appearing confident while doing so; and being willing to Negotiate if needed.

It can be helpful to elicit examples from the group. One example that came up was when a friend constantly borrowed a client’s clothes and did not return them. To discuss this issue with her friend using the acronym, the client would:

  • Describe the situation (“I frequently lend you my clothes, but you do not return them after I ask you to”)
  • Express her feelings (“I feel hurt and angry when you do not return my clothes”)
  • Assert her wants (“I would really appreciate it if you would return my clothes when I ask”)
  • Reinforce why her friend should comply with her request (“I would feel better about our friendship and will not feel resentful toward you”)

After that, the client will:

  • Stay Mindful, ignoring any side attacks (for example, the client’s friend might point out that she never calls her back; the client needs to ignore this and stay focused on her goal)
  • Appear confident (being sure not to be overly aggressive or overly passive)
  • Be willing to Negotiate (“I am willing to remind you once to return my clothes if you will agree to return them when I remind you”)

Adolescent clients enjoy pairing up in group and practicing the application of this acronym in role-plays. Practicing the skill beforehand will help prepare clients to use the skill outside of session.

Radical acceptance

One of my favorite DBT skills is radical acceptance. In the distress tolerance module, this skill can help clients cope with a situation they find particularly upsetting so they can then determine what they have control over in the situation. Linehan encourages clinicians to introduce this skill by telling clients that although pain is a part of life, we suffer only when we refuse to accept that pain. By not accepting reality in a situation that is particularly upsetting or painful, we suffer. Thus, we must radically accept reality, even when it is difficult. For adolescents, this reality might be receiving a bad grade on a test, finding out a friend said something bad about them behind their back or being grounded for what they consider to be an unreasonable amount of time.

One example I use is receiving a cell phone bill that is much higher than I expected it to be. No matter how angry and upset I am or how much I curse my cell phone provider for charging me 10 cents per minute, until I accept the fact that I have received this bill, there is nothing I can do about it. Once I accept the reality that I have received this bill, then I can decide whether to call the customer service number and try to negotiate a reduction in my bill. Or, in the examples mentioned above, once the adolescent accepts the reality in those situations, she can decide whether to discuss the grade with her teacher, confront her friend and communicate her concerns to her parents.

Clients may have difficulty “accepting” reality, especially when the event is particularly hurtful or sad, or if they feel it is unfair. It is important to emphasize to clients that accepting the situation is not the same thing as agreeing with it or saying it is “right.” Rather, they are simply reducing their suffering by accepting reality as it is instead of how they wish it was or how it “should” be. When clients are first learning radical acceptance, Linehan suggests using a different term, such as endure, to help them get past the feeling that they are condoning the situation by accepting it.

I have often had clients who felt they did not need to accept the reality of a particular situation — for example, the death of a loved one. In these instances, I have redirected them to radical acceptance of each aspect of the situation, including the grief that comes along with a difficult loss, the desire not to accept that loss and the time needed to heal from this loss.

Conclusions and resources

DBT is a complex and multifaceted treatment, but clinicians can choose the aspects of DBT they believe will be most helpful to clients on the basis of the client’s age, diagnosis and situation. Although DBT originally was developed for the treatment of borderline personality disorder, research has spread that seems to support its use with a variety of diagnoses and populations. It should be noted, however, that most of the research on these populations is preliminary, and the use of evidence-based treatments for the population with which a counselor is working should be the primary consideration when implementing interventions.

The full 10-day DBT training is offered only to treatment teams through Behavioral Tech (behavioraltech.org), the organization founded by Linehan and her associates for DBT training and resources. However, Behavioral Tech also offers shorter and more specialized trainings for individuals. In addition, many organizations and DBT therapists will offer trainings locally. Furthermore, many texts are available on the topic, including the following resources that I have found helpful.

  • Dialectical Behavior Therapy in Clinical Practice: Applications Across Disorders and Settings edited by Linda A. Dimeff and Kelly Koerner, 2007
  • Cognitive-Behavioral Treatment of Borderline Personality Disorder by Marsha M. Linehan, 1993
  • Skills Training Manual for Treating Borderline Personality Disorder by Marsha M. Linehan, 1993: This text includes all of the skills handouts for each module and guidelines for implementing a psychoeducational skills group. 
  • Dialectical Behavior Therapy With Suicidal Adolescents by Alec L. Miller, Jill H. Rathus and Marsha M. Linehan, 2007: This is a good resource if you’re interested in implementing DBT with adolescents.

Knowledge Share” articles are based on sessions presented at American Counseling Association Annual Conferences.

Karen Michelle Hunnicutt Hollenbaugh, a licensed professional counselor, is an assistant professor in the Department of Counseling and Educational Psychology at Texas A&M University-Corpus Christi. She has spent several years practicing and engaging in research involving DBT. Contact her at Michelle.Hollenbaugh@tamucc.edu.

Letters to the editor: ct@counseling.org

Using neurofeedback to treat ADHD

Heather Rudow February 21, 2013


Attendees of next month’s 2013 American Counseling Association Conference & Expo in Cincinnati will be treated to a new series of conference sessions aimed at shedding light on research by ACA members on topics that uniquely benefit clients. 

Called the Client-Focused Research Series, these 30-minute presentations aim to increase awareness of research that focuses on improving the services that professional counselors provide to clients.

In the weeks leading up to the conference, Counseling Today is speaking with some of the presenters about their research and why they believe it is important to the enhancement of the profession. Next up is Lori A. Russell-Chapin, professor of counselor education and associate dean of the College of Education and Health Sciences at Bradley University. Russell-Chapin, who is also co-director of the Center for Collaborative Brain Research and a member of the Association for Creativity in Counseling and the Association for Counselor Education and Supervision, will be presenting with Theodore J. Chapin on “A Pilot Study of Neurofeedback, fMRI and the Default Mode Network: Implications for the Treatment of ADHD.”

What would you like attendees to take away from your session?

Counselors need to better understand that there is another noninvasive method for the treatment of psychological and behavioral symptoms. Neurofeedback (NFB) is that other option, in addition to counseling and medication. Neurofeedback, a type of neuromodulation, helps to regulate the brain and helps it to perform in a more efficient and effective manner. NFB works with computerized software, an electroencephalograph (EEG) instrument and the principles of operant and classical conditioning to help normalize and strengthen dysregulated brainwaves.

Counselors also need to better understand the importance and role that neuroscience must play in our everyday counseling lives. What we now know about the brain enhances and changes how we conduct counseling. I have been telling our graduate students for years that understanding the brain will change how we do counseling. That knowledge has arrived, and we counselors must understand and utilize those fascinating results. It only makes us more competent in our trade.

How did you first get involved with studying attention-deficit/hyperactivity disorder (ADHD)?

Whenever I would go into the school system to help our student counselors, there always seemed to be so many young children who had symptoms of ADHD. In our private practice it is also a prevalent concern. ADHD is the most common childhood psychiatric disorder, with a cumulative incidence reaching 7.5 percent by age 19 (Barbaresi, Katusic, Colligan, Weaver, Pankratz & Mrazek, 2004). 

Why did you decide to perform this study?

According to Konrad and Eickhoff (2010), there has been a shift of focus from regional brain pathology in children with ADHD to dysfunction in distributed network organization. Because of that belief, I took the opportunity to write a proposal for monies through our Center for Collaborative Brain Research. Our team of researchers did pre- and post-tests with fMRIs to test the ADHD hypothesis of the dysfunctional distributed network. Neuroimaging provides researchers much more advanced methods of understanding the brain and its functions and structures.

What surprised you most as you compiled your results?

Our research team certainly wanted to validate and replicate the efficacy of NFB in the treatment of ADHD, which we were able to state. However, in our pilot study, finding that the Default Mode Network (DMN) was consolidated and, even more importantly, normalized to some extent after 40 sessions of NFB was exciting and remarkable. Many researchers believe that the DMN is essential to our everyday functioning especially in the world of subjective, internal functioning of the environment around us. Often children with ADHD have great difficulty activating the DMN during a resting state or quiet time. The post-fMRIs showed that activation during the resting state after 40 NFB sessions.

Why do you feel this kind of ADHD research is important?

Further advancing knowledge is always an important reason to conduct research. Taking that knowledge and being able to offer those results to children and parents as another type of treatment for ADHD that is intrinsic, noninvasive and long-lasting is a “breath of fresh air” compared to the many side effects of stimulant medications.

Who do you feel is the best audience for this session?

Our workshop would be appropriate for any counselor who wants to know more about additional treatments for children with ADHD. It is just fascinating to see the brain results that the advancements in neuroscience offer. 

Is there anything else you would like to add?

I have been providing individual counseling for several decades. I know counseling works and helps people change their lives. My neurotherapy and neurofeedback training has changed how I conduct counseling and my view of the counseling world. It has strengthened my skills and helped me have better outcomes for my clients.

 Heather Rudow is a staff writer for Counseling Today. Contact her at hrudow@counseling.org.