Tag Archives: Children & Adolescents

Girls daring greatly

By Sabrina Marie Hadeed November 24, 2014

When discussing the idea of girls in the wilderness, the topic of vulnerability comes up often. Typically it is in the context of how girls are vulnerable in fragile ways that we should protect or shelter. However, having been a teenage girl myself, and now having worked as an adolescent WildernessGirlsmental health therapist for nine years, I can confidently say that vulnerability among girls in the wilderness has more to do with courage and resilience than anything else.

Brené Brown is one of the world’s leading researchers on the study of vulnerability and shame. In her most recent book, Daring Greatly: How the Courage to Be Vulnerable Transforms the Way We Live, Love, Parent and Lead, she highlights relevant themes such as learning to embrace imperfections, letting the people we love struggle and other elements of healing our shame. The book’s title was inspired by Theodore Roosevelt’s “Citizenship in a Republic” speech (1910), in which he said, “It is not the critic who counts; not the man who points out how the strong man stumbles, or where the doer of deeds could have done them better. The credit belongs to the man who is actually in the arena, whose face is marred by dust and sweat and blood; who strives valiantly; who errs, who comes short again and again, because there is no effort without error and shortcoming; but who does actually strive to do the deeds; who knows great enthusiasms, the great devotions; who spends himself in a worthy cause; who at the best knows in the end the triumph of high achievement, and who at the worst, if he fails, at least fails while daring greatly, so that his place shall never be with those cold and timid souls who neither know victory nor defeat.”

I have witnessed countless examples of girls daring greatly in the arena of my adolescent therapeutic wilderness group in Bend, Oregon. As we drive out to our remote wilderness use area, my thoughts are filled with a review of the clinical conceptualization of each client. I systematically picture the face of each girl and review the presenting concerns, clinical assessment and other data relevant to the case. Anxiety, depression, history of self-harm and suicide attempts, defiance, drug and alcohol abuse, trauma, history of being bullied or bullying, and tumultuous family relationships are among the most common clinical features represented in my group at any given time. I also consider the strengths and innate potential that each girl possesses, wondering what has stood in the way of the maturity and expression of those strengths. My mind then wanders to the awe of watching nature (the wilderness) help each girl peel back the layers of unnatural overstimulation resulting from daily technology immersion and the false faces of social media relationships.

My teenage years took place before the era of Facebook and cell phones. I am astounded by the resilience that today’s adolescents must possess in order to survive the fast-paced, often cruel and technologically advanced world in which we now live. Many of the adolescent girls with whom I work have spent precious little time connecting with nature or disconnecting from their phones, televisions, computers and social media sites. Few have ever slept under the stars or stopped to listen to the wind whispering through the trees. In fact, most of the teenage girls I work with initially find it very uncomfortable to be in the remote wilderness. I commonly hear “I’m not good at being alone with my thoughts!” or “I can’t possibly be expected to sit and reflect; it’s too hard for me!” and “I need counseling, not sitting in the middle of nowhere!” These protests are understandable because these girls never learned how to sit by themselves and connect with nature. Instead they are used to being surrounded by any number of distractions that encourage disconnection from nature and the here and now.

One day, I arrived after my long reflective drive to the remote site where my group was camping. With my trusty, nature-loving golden retriever by my side, I exited our burly off-road vehicle, took a deep breath of the warm Cascades air and hiked up the barely visible dirt trail. Taking a final step over the gnarled volcanic rock, I could see the group of girls in the distance. Instantly, I was struck not by what I saw but by what I heard.

My ears and heart were suddenly being serenaded by six harmonizing girls. They were standing in a circle, all eyes focused on the group-appointed 17-year-old pseudo choir director. Their bodies stood like gracefully poised trees as they gently sang out. But they weren’t singing a song by any artist WildernessHikecommonly attached to their generation, such as Lady Gaga or Miley Cyrus. Instead they were harmonizing so beautifully to “Rose Red,” a ballad from the Elizabethan era.

There was a disorienting two-second lapse of time where I had to remind myself where I was standing. For one lovely moment that day, we were no longer in the Oregon desert in a therapeutic wilderness program defined by mental health struggles and adolescent angst. Instead we were transported to a magical place where teenage girls put their pain aside to learn a song together, letting their voices sing out and dance along the juniper tree-spotted hills of the Cascades.

It was beyond any brilliant counseling technique I could have applied. The moment was made possible through the influence of a connection to nature, a disconnection from the distractions of cell phones and social media sites, a positive group culture, the ongoing collaborative support of the entire treatment team and, of course, the courage of six teenage girls. The girls had been able to develop emotional safety within the group and increase their self-confidence, which gave them the courage to “dare greatly.” I believe the power of vulnerability and daring greatly can be linked to reconnecting with one’s self through nature and disconnecting from the conveniences of our technologically smothered first-world lives.

In 2011, Brené Brown wrote, “I define connection as the energy that exists between people when they feel seen, heard and valued; when they can give and receive without judgment; and when they derive sustenance and strength from the relationship.”

Among the circle of singing girls there were no perfect vocalists, no dominating ego, no cyberbullies, no gestures of self-harm, no competing debutants. There was only honest harmonized courage and the presence of emerging self-acceptance and genuine connection. Moments like that remind me how the influence of nature can transform and why the power of vulnerability is born from the courage to dare greatly.

 

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Sabrina Marie Hadeed is a licensed professional counselor, national certified counselor and approved clinical supervisor. She is a primary therapist at Second Nature Cascades and a doctoral candidate at Oregon State University. Contact her at sabrinamariecounseling@gmail.com.

 

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Wilderness therapy: A closer look

See the upcoming January issue of Counseling Today for an in-depth feature article on wilderness therapy (to which Hadeed contributed).

Entering the danger zone

By John Sommers-Flanagan October 28, 2014

For the most part, the United States lacks a coherent and systematic approach to sexual education. Instead, as lampooned in an online issue of The Onion, sex education is typically informal, unorganized and inaccurate. The Onion article describes a scene in which a 10-year-old boy takes his 8-year-old cousin behind his parents’ garage with a page ripped out of a magazine and shares “the vast misguided knowledge of human sexuality he had gleaned from classmates’ hearsay as well as 12 minutes of a Real Sex episode he watched in a hotel room once.” The older boy recounts his rationale: “Every time people have sex the woman has a baby, and I just want [my younger cousin] to be completely prepared before getting naked with a girl.”

The good news is that The Onion deals in news satire. The bad news is that the current state of sex education in our country isn’t much better than the fictional version portrayed in The Onion.

Image of youth looking at laptop computerConsider that a report this past April from the Centers for Disease Control and Prevention indicated that more than 80 percent of adolescents between the ages of 15 and 17 have no formal sexual education before actually having sex. If teenagers have no formal sex education, then what informal sex education do you suppose they take with them into their first sexual experiences?

One such source of informal sex education is pornography. In 2009, University of Montreal professor Simon Louis Lajeunesse designed a study to evaluate how pornography use affects male sexual development. He planned to interview 20 males who had viewed pornography, then compare their responses with those of 20 males who had never viewed porn. Remarkably, Lajeunesse had to abandon his project because he couldn’t find any college-aged males who hadn’t already viewed porn.

Other researchers report similar experiences. It appears that most boys, rather than learning about sex from a well-meaning, albeit uninformed cousin, get their information from the pornography industry … and my best guess is that the porn industry isn’t focusing on the best interests of American youth. This is one way in which reality may be worse than The Onion’s satiric version of events.

The absence of formal and accurate sexual education is a particularly American problem that may find its way into the offices of professional counselors. Many young males probably have little basic knowledge about sex and sexuality, or hold unhelpful ideas. Some will have porn addictions. Others will want to talk about how pornography may be affecting their real sex lives. You may also have clients who are concerned about their partner’s or potential partner’s porn viewing behaviors. Working with young (and older) males (and females) who want to talk about their sexual knowledge, beliefs and behaviors, including watching pornography, is both a challenge and an opportunity for professional counselors.

Counselors have an ethical mandate to strive toward competence. As articulated in the multicultural counseling literature, this requires cultivating personal awareness, gathering knowledge and developing skills.

Awareness: Expanding your comfort zone

Talking about sex, sexuality and sexual attraction can be difficult at every level. Think about yourself: How easy is it to talk about sex with your supervisor, colleagues, students or clients? Your own experience may give you a glimpse into how challenging it can be to broach the topic of sex — even for professionals.

In comparison, it’s probably an understatement to say that it is especially difficult for boys to initiate a conversation about sex or sexuality with a professional counselor. This is why counselors who work with boys should become comfortable initiating conversations about sex. If you don’t ask at least a few gentle, polite, yet direct questions, you may be waiting a long time for the boy in your office to bring up the subject.

On the opposite extreme, some young clients will jump right into talking about sexuality and push us straight out of our comfort zones. Recently, I was working with a 16-year-old boy who described himself as a polyamorous “furry” (which I later learned involved sexualized role-playing as various animals). Admittedly, it was a challenge to maintain a nonjudgmental attitude. But without such an attitude, we wouldn’t have been able to have repeated open and useful conversations about his sexuality and sexual identity development.

Knowledge: The effects of pornography on boys and men

Many potential areas related to sexuality deserve attention, focus and discussion in counseling. But because pornography and mixed messages about pornography are everywhere, it can be an especially important subject.

Most counselors probably believe that repeated exposure to pornography has a negative impact on male sexual development. This negative impact is likely exacerbated by the fact that most boys aren’t getting any organized, balanced and scientific sexual information. Nevertheless, within the dominant American culture, there remains strong resistance to both sex education and pornography regulation. Even in a recent issue of Monitor on Psychology, the authors of an article questioned whether porn is addictive and blithely noted that “people like porn.”

It’s not surprising that porn has advocates. After all, it’s estimated to be a $6 billion-plus industry. In addition, media outlets explicitly and implicitly use pornlike sexuality to attract an audience and sell products. Recently we’ve seen the increased use of hypermasculine male body types in the media, but most of the rampant sexual objectification still focuses on young female bodies.

Given that sexual development includes a complex mix of culture, biology and life experience, it’s not surprising that researchers have had difficulty isolating pornography as a single causal factor in male sexual developmental outcomes. However, a summary of the research indicates that as the viewing of pornography increases, so does an array of negative attitudes, behaviors and symptoms. Generally, increased exposure to pornography is correlated with:

  • More positive attitudes toward sexual aggression, increases in sexual aggression, multiple sexual partners and engaging in paid sex
  • Increased depression, anxiety and stress, and poorer social functioning
  • Positive attitudes toward teen sex, adult premarital sex and extramarital sex
  • More positive attitudes toward pornography and more viewing of violent or hypersexual pornography
  • Higher alcohol consumption, greater self-reported sexual desire and increased rates of boys selling sexual acts

In contrast to these findings, a 2002 Kinsey Institute survey indicated that 72 percent of respondents considered pornography to be a relatively harmless outlet. This might be true for adults. I recall listening to B.F. Skinner talk about how older adults could use pornography as a sexual stimulant in ways similar to how they use hearing aids and glasses.

But the point isn’t whether people like porn or whether porn can be relatively harmless for some adults. The point is that pornography is a bad primary source of sexual information for developing boys and young men. As a consequence, it’s crucial for counselors who work with males to be knowledgeable about the potential negative effects of pornography.

Skills: How can counselors help?

A big responsibility for professional counselors who work with boys is to consistently keep sex and sexuality issues on the educational and therapeutic radar. This doesn’t mean counselors should be preoccupied with asking about sex. Rather, we should be open to asking about it, as needed, in a matter-of-fact and respectful manner.

As with most skills, asking about sex and talking comfortably about sexuality requires practice and supervision. But as Carl Rogers often emphasized, having an accepting attitude may be even more important than using specific skills. This implies that finding your own way to listen respectfully to boys (and all clients) about their sexual views and practices is essential. It also requires openness to listening respectfully even when our clients’ sexual views and practices are inconsistent with our personal values. As with other topics, if we ask about it, we should be ready to skillfully listen to whatever our clients are inclined to say next.

Case example

Some years ago, I had a young client named Ben who was in foster care. We started working together when he was 10 and continued doing so intermittently until he was 17.

When Ben was approximately 13, I routinely started asking him about possible romance in his life. He typically redirected the conversation. Occasionally he gave me a few hints that he wanted a girlfriend, but he mostly still seemed frightened of girls. As my counseling with Ben continued, I became aware that I had been conspiring with him to avoid talking directly about sex, possibly because I was afraid to bring it up.

I finally faced the issue when I realized (far too slowly) that Ben had no father figure in his life and, thus, I was one of his best chances at having a positive male role model. With encouragement from my supervision group, I was able to face my anxieties, do some reading about male sexual development and finally broach the subject of having a sex talk with Ben.

Toward the end of a session I said, “Hey, I’ve been thinking. We’ve never really talked directly about sex. And I realized that maybe you don’t have any men in your life who have talked with you about sex. So, here’s my plan. Next week we’re going to have the sex talk. OK?”

Ben’s face reddened and his eyes widened. He mumbled, “OK, fine with me.”

The next session I plowed right in, starting with a nervous monologue about why talking directly about sex was important. I then asked Ben where he’d learned whatever he knew about sex. He answered, “Sex ed at school, some magazines, a little Internet porn and my friends.”

I felt a sense of gratitude that he was listening and being open, even if we were both feeling awkward. We talked about homosexuality, pornography, sexually transmitted diseases, pregnancy, contraception and emotions. I tried to gently warn him that too much porn could become way too much porn. He agreed. He told me that he didn’t feel like he was gay but that he didn’t have anything against gays and lesbians. At the end of the conversation, we were both flushed. We had stared down our mutual discomfort and navigated our way through a difficult topic.

Professional sex educators emphasize that parents shouldn’t have just one sex talk with their kids; they should have many sex talks. What I thought was THE talk with Ben turned into something we could revisit. Over the next two years, Ben and I kept talking — off and on, here and there — about sex, sexuality and pornography.

Final thoughts

Boys are a unique counseling population, and sex is a hot topic. Together, the two provide both challenge and opportunity for professional counselors. As counselors, we should work to develop our awareness, knowledge and skills for talking with boys about sex and sexuality. You may not be the perfect sex educator, but when the alternatives for accurate information are pornography or someone’s uninformed older cousin, it becomes obvious that having open conversations about sex with boys is an excellent role for counselors to embrace.

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Readings and resources for working with boys and men

  • A Counselor’s Guide to Working With Men, edited by Matt Englar-Carlson, Marcheta P. Evans & Thelma Duffey, 2014, American Counseling Association
  • “Addressing sexual attraction in supervision,” by Kirsten W. Murray & John Sommers-Flanagan, in Sexual Attraction in Therapy: Clinical Perspectives on Moving Beyond the Taboo — A Guide for Training and Practice, edited by Maria Luca, 2014, Wiley-Blackwell
  • Guyland: The Perilous World Where Boys Become Men, by Michael Kimmel, 2010, Harper Perennial
  • Tough Kids, Cool Counseling: User-Friendly Approaches With Challenging Youth, second edition, by John Sommers-Flanagan & Rita Sommers-Flanagan, 2007, American Counseling Association
  • The Macho Paradox: Why Some Men Hurt Women and How All Men Can Help, by Jackson Katz, 2006, Sourcebooks
  • The Good Men Project: goodmenproject.com

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John Sommers-Flanagan is a counselor educator at the University of Montana and the author of nine books. Get more information on this and other topics related to counseling and parenting at johnsommersflanagan.com.

Letters to the editor: ct@counseling.org

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Responding to the rise in self-injury among youth

By Brent G. Richardson & Kendra A. Surmitis October 23, 2014

The prevalence of nonsuicidal self-injury (NSSI) among adolescents and young adults has rapidly and significantly increased in recent years, leading mental health professionals and researchers to describe its pervasiveness as epidemic. By definition, a person does not engage in NSSI with intent Photo of authors Brent Richardson and Kendra Surmitisto die. Rather, NSSI is a means of regulating emotions, relieving tensions, managing dissociative symptoms and influencing others. It is critical that counselors working with youth gain an understanding of NSSI and recognize its prevalence within the adolescent population.

There is growing evidence that many teenagers who engage in NSSI have been influenced by their peers. In 1985, Barent Walsh and Paul Rosen defined self-injury contagion in two ways:

1) When acts of self-injury occur among two or more persons within the same group within a 24-hour period

2) When acts of self-injury occur within a group of statistically significant clusters or bursts

The primary focus of this article is to identify environments that present a high risk for self-injury contagion and to suggest opportunities for counselors to minimize and prevent contagion when working with adolescents.

Benefits and pitfalls of group work

Many programs designed to treat adolescents who self-injure include group therapy as an essential ingredient in the treatment milieu. S.A.F.E. (Self Abuse Finally Ends) Alternatives, founded in 1985 by Karen Conterio and Wendy Lader, was the first treatment facility designed specifically for people who self-injure. Since its inception, clinicians at S.A.F.E. Alternatives have used group therapy as a central feature of its treatment programs. Dialectical behavior therapy (DBT), which combines individual therapy, group skills training and family education, has emerged as one of the most effective treatments for adolescents who are suicidal and/or self-injure. Many of the key skills needed to reduce self-injurious behaviors (for example, emotional regulation, distress tolerance and interpersonal communication skills) are learned and practiced in group therapy. Solution-focused therapist Matthew Selekman recently developed a nine-session Stress-Busters’ Leadership Group geared specifically toward adolescents who engage in self-destructive behaviors. The group is applicable in both school and community settings. While these group approaches (S.A.F.E. Alternatives, DBT and Stress-Busters) have several differences, it is important to note that each is largely didactic, highly structured and skill-based.

Group work is appealing both to adolescents and counselors for a number of reasons. For logistical and developmental reasons, group homes, residential facilities and hospitals typically utilize various forms of group work as their primary mode of treatment. Groups are more efficient and cost-effective than individual approaches because they enable counselors to work with more clients. In addition, group work tends to be a better developmental fit for adolescents than individual therapy, and adolescents often prefer it because a significant amount of social learning occurs in the context of formal and informal groups (for example, family group, classroom group, social group and sports teams).

Youth who self-injure tend to feel isolated and disconnected. Although individual counselors can inform youth that they are not alone, the group process allows them to experience a sense of universality with their peers, while learning from others who are at different stages in the recovery process. By assisting and supporting others, members begin to see themselves in a different light. One of the most effective ways to boost a youth’s self-esteem and self-confidence is to structure situations in which he or she can help others and feel altruistic.

Despite the potential benefits of using groups as a component in treating those who self-injure, there are also possible pitfalls that could disrupt the process or even increase self-injurious behaviors. Walsh, author of Treating Self-Injury, says counselors should be mindful that anytime individuals who self-injure are treated in groups, there is an increased risk for a contagion effect. In addition, he warns that groups that are largely cathartic in nature — wherein youth are encouraged to openly express their emotions and share traumatic experiences — are often counterproductive with this population. These types of groups can increase the risk of contagion because open discussion of self-injury antecedents, behaviors and consequences can be exceptionally triggering for some young clients.

Many clinicians and researchers assert that group leaders should structure activities that focus on empowerment and replacement or coping skills training, while prohibiting detailed discussion of self-injury. This can be challenging for counselors because sharing and hearing details about self-injury can be so alluring for both counselors and group members. Adolescent clients may view group therapy as an opportunity to compare wounds and share stories. These disclosures should be severely limited or prohibited from the onset, however. Counselors may want to acknowledge that discussing self-injury in great detail may be important but emphasize that those details should be shared in individual therapy rather than with group members.   

In summary, NSSI groups are most likely to be effective if:

1) Group leaders have significant training and understanding of treating self-injury and managing contagion

2) Membership is closed to enhance cohesion and trust

3) The group is governed by strict rules prohibiting the discussion of details of self-injury and the sharing of wounds or scars in the group

4) As with DBT groups, the sessions are highly structured, didactic and focus on teaching new skills and behaviors (for example, emotional regulation, mindfulness, self-soothing, distress tolerance and exercise) to help reduce further incidents of self-injury

Benefits and pitfalls of residential facilities

Similar to treatment in group therapy, clinicians who work with youth in residential treatment can be effective in counteracting self-injury, provided they follow the proper precautions.

The residential population is likely at higher risk for contagion due to peer influence and the prevalence of severe psychopathology such as eating disorders and issues with affective regulation. In fact, a number of researchers have observed that NSSI occurs in significant clusters in residential settings, including community-based group homes, special education boarding schools, juvenile detention facilities and psychiatric inpatient settings. Recognizing the potential for contagion in a residential population allows for appropriate precautions when determining the benefits of residential treatment on a case-by-case basis, and it can aid in the appropriate response to NSSI.

Several studies have found that self-injurious behaviors often increase for adolescents, regardless of Photo of self-injury wounds on armwhether they have a prior history of self-harm, during residential treatment. Clinical settings that feature multiple youth living together who exhibit emotional dysregulation can aggravate dysfunctional behaviors, including NSSI. Consequently, the increased likelihood of exposure to self-injury in a residential facility leads to the question of whether the benefits of inpatient care are worth the potential risks associated with contagion.

Despite concern for social contagion, several arguments can be made in favor of choosing residential treatment for NSSI. For example, cases that include high-risk behaviors such as clinically significant disordered eating require structured, intensive treatment. In similar circumstances, placement in a residential facility may be warranted, even if nonresidential treatment may pose less risk of self-injury contagion.

The first step in response to the risk of social contagion is making the appropriate referral to residential care on an individual client basis, while avoiding unnecessary hospitalization. Within the residential setting, precautions guide clinicians toward the appropriate response to NSSI. These responses include educating the individual client, confronting triggers of social contagion and using encouragement to motivate youth to build and share healthy coping skills.   

Subsequently, many of the challenges and recommendations for counselors who work in residential facilities are similar to those provided for group counselors. Although communicating with peers in a communal environment is beneficial for those who feel isolated and may benefit from peer support, mental health counselors are advised to educate residents on the negative effects of sharing stories of self-injury. These clients should instead be instructed to share stories of healing and healthy coping behaviors. 

Benefits and pitfalls of websites and message boards

Although the Internet is a potentially valuable source of support and information for self-injurers, various websites can also be breeding grounds for social contagion. Approximately 93 percent of American youth ages 12 to 17 use the Internet, and nearly two-thirds of adolescent Internet users go online daily. These numbers are growing every day. In the past decade, the number of websites intended for or about people who self-injure has increased. Research conducted in 2007 by Janis Whitlock, Wendy Lader and Karen Conterio revealed there were more than 500 message boards focused on self-injury. These researchers also observed the parallel between the increase in self-injury websites and the growth in self-injury awareness in society. Internet message boards provide a potent medium for bringing together adolescents who self-injure.

These self-injury websites and message boards offer a number of potential benefits. The Internet may have particular relevance and appeal for adolescents who are socially avoidant or feel marginalized. These youth may feel extreme relief upon finally being able to make meaningful connections with individuals who share similar concerns and experiences. The anonymity of these sites might also encourage youths to share more frequent and truthful disclosures about their feelings and behaviors. Positive peer pressure is another potential benefit. As is the case in group counseling, these adolescents might more readily accept online feedback from peers that encourages them to practice safer, more productive ways of expressing their emotions.

Thus, it is important that counselors not minimize the perceived value that these sites have for young clients who self-injure. Though social scientists and mental health professionals often focus on the potential harm of these discussion groups, adolescents who use them tend to self-report positive experiences as a result of their participation. For example, in one survey of self-harm discussion group members, Craig Murray and Jezz Fox found that the majority of respondents reported having reduced the frequency and severity of their self-injurious behaviors. The respondents attributed this largely to the support and guidance they found online.

Whitlock and her colleagues were some of the first researchers to study the content of self-injury message boards to better understand their role in sharing information about self-injurious practices and influencing help-seeking behaviors. These researchers found that the most common type of exchange on the message boards involved providing informal support to other posters through comments such as “We’re glad you’ve come here” and “Just relax and try to breathe deeply and slowly.”

However, in addition to the supportive communication found on NSSI-related sites, researchers also found dangerous messages. While 44 percent of all help-seeking posts presented favorable attitudes toward seeking mental health treatment, approximately 20 percent of the posts discouraged individuals from seeking treatment and/or voiced negative views about therapy. There was also considerable discussion about better ways to conceal scars and maintain secrecy.

These researchers warned that self-injury message boards expose vulnerable youth to a normalizing environment of encouragement for self-injury and hold the potential for fueling social contagion. On several sites, members shared new and often more dangerous techniques and instruments for cutting and even offered links to sites where self-injury paraphernalia could be purchased. Sites that feature graphic depictions of self-injury, including many videos on YouTube, can be highly suggestive or triggering to other self-injurious participants. Unfortunately, those who self-injure can become better at self-injury by learning from others they meet online. Some posters use chat rooms to coerce others, model self-destructive behaviors, compete with others and discourage others from stopping their self-injurious behaviors or seeking help.

As is evident, self-injury websites and message boards are helpful for some and counterproductive for others. Regardless, this needs to be an area of therapeutic inquiry. In fact, the popularity of the Internet among adolescents presents a crucial argument for assessment of Internet use in general, as well as specific assessment of Internet exposure to self-injury. Mental health professionals should therefore educate themselves about various websites for self-injurers (some recommended sites are included in the next section).

Whitlock and her fellow researchers suggested that clinicians maintain a curious, neutral, nonjudgmental tone when asking questions such as the following:

  • How comfortable do you feel hearing stories from others who self-injure?
  • Have you shared your own story? How did you feel?
  • What do you like most about having friends whom you really know only through the Internet?
  • How honest are you when you share information on the Internet? (Do you minimize or tend to embellish?)
  • Do you ever take advice from Internet friends? If so, can you provide examples of advice that you used?

Some NSSI sites have minimal or no monitoring for potentially dangerous content. If there are moderators, they typically have minimal or no training in mental health. With certain clients, counselors might assess that it is best to be direct in encouraging or discouraging particular sites or interactive behaviors. Counselors can clarify concerns about why some sites might be traumatic or triggering and therefore countertherapeutic. These direct suggestions will likely be more fruitful with adolescents who have entered counseling voluntarily, begun to develop a therapeutic relationship with the counselor and voiced a desire to stop or reduce self-injury.

Summary recommendations

In this article, several mediums have been identified as environments at high risk for social contagion of NSSI — namely group treatment, residential facilities and social media. Key considerations for the prevention of social contagion were identified. These include:

  • Developing a clinical understanding of social contagion and its significant impact on the adolescent population through training and further research
  • Working with clients who engage in NSSI to develop awareness of appropriate environments to discuss their self-injury stories, such as individual therapy sessions
  • Asking clients who self-injure to cover up scars, wounds and bandages that can be triggering
  • Prohibiting graphic detail of NSSI at the onset of group therapy
  • Incorporating strength-based strategies that encourage healthy coping behaviors in treatment
  • Assessing client Internet use, with specific attention paid to exposure to self-injury imagery
  • Determining the appropriate level of treatment and avoiding unnecessary hospitalizations that may invoke NSSI in vulnerable clients
  • Instructing clients to share stories of healing and healthy coping behaviors to decrease the opportunity for contagion, while inspiring altruistic motives in a group environment

Furthermore, the role of mental health counselors working with youth engaging in NSSI extends past the therapeutic relationship encountered in treatment to the family system and school setting to which the child is connected. Providing appropriate referrals to information for concerned individuals in the child’s life, such as parents and other caretakers, is an important action in attending to NSSI and contagion among peers. The following websites provide helpful information grounded in clinical research and professional standards.

Empowering family members and other members of the client’s care system to understand self-injury will help them to comprehend the messages sent by the child who is engaging in the behavior, while promoting an atmosphere of awareness to counteract opportunities for contagion. As a provider of information, it is crucial that the counselor is clear when it comes to appropriate Internet material, such as empirically validated information for families, and the potential misinformation provided by sites containing blogs and graphic imagery. The prevention of contagion begins with understanding NSSI in youth and empowering the people in their lives who also share in the opportunity to preclude self-injury among adolescents.

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This article was adapted from a previous article published in the American Mental Health Counselors Association’s Journal of Mental Health Counseling.

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Knowledge Share articles are developed from sessions presented at American Counseling Association conferences.

Brent G. Richardson is chair of the Department of Counseling at Xavier University in Cincinnati. Contact him at richardb@xavier.edu.

Kendra A. Surmitis is an assistant professor of counseling in the Department of Educational Psychology at Northern Arizona University. Contact her at kendra.surmitis@nau.edu.

Letters to the editor: ct@counseling.org

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Facebook: Don’t let friends’ cries for help go unanswered

By Bethany Bray October 7, 2014

“I can’t handle life right now.”

“Didn’t get out of bed today.”

#worthless

For those who use Facebook, status updates, comments and hashtags such as these may be all too familiar. In this electronic age, people often turn to the availability and relative anonymity of social media to vent frustrations and sad feelings – or indications of deeper, more serious distress.

With this in mind, Facebook recently introduced a guide to help users know what to do if a friend posts a suicide threat or other serious cry for help.

facebookThe guide, which Facebook created in partnership with the nonprofit Jed Foundation and Clinton Foundation, was launched Sept. 10, on World Suicide Prevention Day.

Dubbed “Help a Friend in Need,” the guide is available on Facebook’s safety materials page and will also be promoted in Facebook ads geared toward college students.

Close to 90 percent of young adults (ages 18 to 29) use Facebook, according to a recent Pew Research Center study. Adults ages 30 to 49 are not far behind, with 82 percent reporting that they use Facebook.

The social network’s three-page “Help a Friend in Need” guide lists red flags and warning signs users should look for, as well as guidance on how to respond and ways to get help, including suicide hotline information. The material is based on evidence-based practices, according to the guide’s creators.

In the guide, Facebook urges users to trust their instincts. “If you see someone posting messages, photos, videos, links, comments or hashtags that suggest the person is in emotional distress, you should reach out and get them the help they may need,” the guide says. “… Never be afraid to give your friend a call, pay a visit, or send them a Facebook message to let them know you are concerned, and offer to help connect them with any extra support needed.”

The guide urges users to reach out directly to the individual, either in person or electronically, rather than clicking the “like” button on a concerning post, which could be misunderstood by the individual in distress.

If the individual declines to talk about what is troubling him or her, Facebook users are advised to say, “It’s OK if you don’t want to talk to me, but it is important that you talk to someone.” Options such as a mental heath center, college counseling office or chaplain are suggested.

“No matter what, you shouldn’t be embarrassed or worried about offending or upsetting your friend,” the guide says. “Helping your friend may take some courage, but it is always worth the effort to support their health and safety.”

The guide, launched for both Facebook and Instagram in the United States, is also available to users in seven European countries and Canada.

 

 

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Find the “Help a Friend in Need” guide at  fb.me/helpafriend

 

A full slate of safety materials, including information for parents, teens and educators, is available at facebook.com/safety

 

Facebook’s suicide prevention page: facebook.com/help/suicideprevention

 

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Red flags

Be aware of statuses/posts, messages, photos, videos, links, comments or hashtags that include the following themes:

  • Feeling alone, hopeless, isolated, useless or a burden to others: “I feel like I’m in a black hole”; “I don’t want to get out of bed…ever”; “Leave me alone”; “I can’t do anything”
  • Showing irritability and hostility that is out of character: “I hate everyone”; “F*@K the world”
  • Showing impulsive behaviors such as driving recklessly, a significant increase in substance use or taking other risks
  • Insomnia posts: “3 a.m. again and no sleep”
  • Withdrawal from everyday activities: “Missed another chem lab – I’m such a waste”; “Another day in bed under the covers”
  • Use of negative emoticons: for example, repeatedly using emoticons that suggest someone is feeling down or thinking about using a tool to hurt themselves.
  • Use of concerning hashtags: #depressed #lonely #whenimgone #noonecares #suicidal #selfharm #hatemyself #alone #sad #lost #worthless #neverenough #givingup
  • On Facebook’s “News Feed” and Instagram’s “Following Activity,” you can see the accounts and posts people start to follow. If you notice a friend liking or following feeds or posts that promote negative behaviors, even if they aren’t sharing concerning content themselves, it may serve as a warning sign that they are engaging with troubling messages or communities.

Source: fb.me/helpafriend

 

 

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Related reading

 

From the September issue of Counseling Today: “Losing Face: How Facebook disconnects us” ct.counseling.org/2014/08/losing-face-how-facebook-disconnects-us/

 

Online exclusive: “Critical social skills to incorporate in a 21st century social skills group” ct.counseling.org/2014/09/critical-social-skills-to-incorporate-in-a-21st-century-social-skills-group/

 

 

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Bethany Bray is a staff writer for Counseling Today. Contact her at bbray@counseling.org

 

Follow Counseling Today on Twitter @ACA_CTonline and on Facebook: facebook.com/CounselingToday

 

Critical social skills to incorporate in a 21st-century social skills group

By Aaron McGinley September 16, 2014

If you provide counseling services to clients who have autism, or any of several other mental health conditions, at some point you will inevitably work with them on social skills. And if you are like many of the practitioners I know, you have a sizeable collection of the various resources and materials available to support work on social skills. Why shouldn’t you? The works of Jed Baker, Michelle Garcia Winner and Carol Gray, among others, are full of insightful and engaging techniques to help polish interpersonal skills.

The challenge for many clinicians is how to fit these various curriculums into a world filled with Instagram, Facebook and the dreaded Snapchat. To update an old saying, this isn’t your father’s selfiesocial world.

The bulk of most social skills curriculums are appropriately focused on “in-person” social skills. Issues such as personal space, body language, conversational cues and job interview skills still offer overwhelming challenges for some individuals with special needs. But the social norms found in everyday interactions are further complicated by rapidly evolving technologies and social media platforms. Effective social skills instruction needs to reflect this reality and the changing norms that accompany these rules. If we are going to teach social skills effectively, our curriculums must reflect the unwritten rules of the 21st century.

Anecdotally, I have found that clients benefit from the same instructional strategies that are used with more traditional social skills training programs. Visual supports, direct instruction, role-plays, social cognition exercises and other strategies can still work to address Facebook faux pas, Snapchat social rules and email etiquette. However, such difficulties cannot just be added in on the fly. Because smartphones and tablets are fully integrated into today’s world, they also need to be fully integrated into any robust social skills curriculum.

 

The art of the ‘selfie’

Although “selfies” are a popular part of youth culture, and a tempting means for socially awkward youth to engage with their social world, the wrong type of selfie can sabotage a youth’s reputation, or worse, compromise his or her safety.

A social skills instructor might help a client recognize some of the unwritten social rules of selfies:

  • Don’t post more than one selfie in a day
  • Try to post selfies only at exciting new events
  • When possible, try to include other people in your selfie

 

Social media savvy

The time is gone when social skills instructors could easily redirect residents away from computers and toward the day-to-day challenges of social interactions. Social media use is now a regular part of most cultures, and the socially awkward youth cannot easily avoid the world of social media. At the same time, social media can be a source of challenges such as cyberbullying, Internet safety issues and other difficulties that are beyond the scope of this article.

With that said, there are some ways that social media savvy can be combined with common social skills lessons:

  • When doing a lesson plan on hygiene/fashion and reputation, have students show or draw their Facebook profiles for feedback from the group.
  • When discussing conversational skills such as active listening, discuss how these rules apply to online conversations.
  • When discussing boundaries, bring up such issues as what sorts of comments should go on a public wall, how often to “like” someone else’s pictures and similar issues related to conversational boundaries.

 

Email etiquette

Politeness, self-advocacy, follow-through, conciseness and other important social skills do not stop at the Internet’s door. When working with students on social skills, it might be helpful to support them by offering email etiquette lessons.

  • When running a lesson on “think before you speak,” suggest that students find a point person to run sensitive emails by before sending them.
  • When facilitating a discussion about self-advocacy, discuss how to practice self-advocacy in an email.
  • When discussing conversational skills such as manners, touch on how to incorporate these skills in email communications.

 

Let’s talk texting

At some point, many socially awkward young people get involved in tricky texting situations. Some do not recognize the challenges that can come along with “sexting.” For others, the challenges of dealing with unrequited love via text can be too much. A social skills instructor can:

  • Discuss texting styles
  • Help students understand what types of conversations should happen via text
  • Discuss the frequency of texting as it applies to different types of relationships, such as friends, teachers and other social roles

 

Between the time this article was written and posted, online social norms might have evolved dozens of times. But this only underscores the importance of being intentional about incorporating technology etiquette into social skills work. So sit down, pull out your social skills curriculum and ask yourself …“Is my social skills curriculum ready for the 21st century?”

 

 

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Aaron McGinley is student member of the American Counseling Association living in Asheville, North Carolina. In addition to serving as a social skills consultant at Beacon Transitions, an independent living program for young adults, he works as a clinical intern at Caring Alternative as he completes his work toward a clinical mental health counseling degree at Montreat College. Contact him at aaronmcginley001@gmail.com.

 

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