Tag Archives: Children & Adolescents

Case study: The critical need to conduct thorough child assessments

By Gregory K. Moffatt January 29, 2015

“Amanda” sat on the couch across the room from me drawing on a sketch pad. A lovely young girl of 14, she weighed scarcely 100 pounds, and with her cheery and naïve smile, she looked as innocent as they come. If I hadn’t seen attachment disorders many times before, I could easily have been swingsfooled by her carefree air and seemingly open-book candor.

Could this barely pubescent teen really have done what she had been accused of? In my work, I have seen dozens of children who have been accused of animal cruelty, rape and even murder. I knew better than to be fooled by the crafty façade of which children such as this are capable.

 

The case

The call on my cell phone was from a social worker at a foster care agency. As I drove through Atlanta traffic, she explained that two family pets had been horribly violated in a sexual way, with injuries so serious that both dogs had required surgery. The county sheriff’s department was investigating the case, and Amanda was the prime suspect.

Amanda’s background was classic for reactive attachment disorder (RAD). Very early in life, she had been abused both physically and sexually, at which time she was removed from her biological parents’ home and placed in foster care. Early attachment problems were present in her case file, including sexual acting out and some indication of cruelty to animals.

Circumstantial evidence pointed to Amanda as well. She was the caretaker of the pets and was often unsupervised. She was the last person seen with the dogs before their injuries, and her home was in a remote, rural area, making it unlikely that some random perpetrator was at fault.

My heart sank. I felt certain I had another case of a seriously disturbed child, and I made an appointment to do an assessment with Amanda within the next few days.

But things are not always what they seem.

 

The assessment

I easily could have conducted my in-office assessment with Amanda, written my report, submitted my bill and been done with it. But this would not have given me the fullest picture of Amanda and the extenuating circumstances this situation presented.

Prior cases such as Amanda’s that I had worked were clear. Children with RAD often begin displaying disturbing behavior in early childhood, sometimes even in infancy. These behaviors become progressively worse until parents or guardians eventually run out of ideas for coping. By the time they come to my office, these children have often sexually assaulted other children, destroyed property or become incorrigible. None of these things were true for Amanda.

My normal assessment includes, among other things, a number of processes that allow me to observe a child’s sexualization, socialization and attachment. In cases such as this, I also normally conduct a minimum of two different assessment appointments. Children may behave very differently from one day to another, and this practice has helped me avoid many problems over the years.

Amanda passed these assessments with flying colors. I was at a loss because cursory information made her the most likely suspect, but what I saw in my assessment was inconsistent with a young teen who could have so cruelly abused an animal in such a sexual way.

Looking through nearly 10 years of Amanda’s evaluations by psychologists, I found hints of sexualization and cruelty to animals as I had initially been told, but careful reading put this information in a different context. In the child’s early years, there had, indeed, been evidence of sexual acting out as one might see in children with RAD. But interestingly, no one had observed even a single instance of Amanda acting out sexually since she was 6 years old —a span of longer than eight years.

The “cruelty” to animals that existed in her file was, in my opinion, either a very mild form of cruelty or not cruelty at all. Children often hurt animals, sometimes in very serious ways, but my concern is not with the seriousness of the injury. A normal child might seriously injure or even kill a pet by accident. A child with RAD, on the other hand, might torment and torture a pet explicitly for the purpose of causing pain, even if the pet doesn’t end up being seriously injured. These are very different motives. I saw no clear evidence of “cruelty” in the recorded behaviors in Amanda’s file.

But this evidence can be deceptive. Children with RAD often mask their cruel behaviors against both animals and people as seemingly innocent mistakes. I had to be certain I wasn’t missing something with Amanda.

 

Interviews and supporting information:

I needed a fuller picture of Amanda than I could achieve from my office evaluation and the information in her file. One of the many professional hats I wear is that of a homicide profiler. When I am looking at a homicide case, I want to know as much as I can, not only about the homicide but also about the victim, the place, the weapon and the timing of the event. I interview as many people as I can and look at every piece of evidence available to me. In ethnographic research, this is called triangulation (looking at evidence from three or more sources), and Amanda’s case demanded this type of multidirectional examination. I didn’t want to make a decision based simply on my office assessment.

I started my interviews with the foster parents. I needed to know more about Amanda’s history in the nine years they had had guardianship of her, and specifically about the past three or four years. This caring and loving couple had treated Amanda like a daughter since her placement in their home, and they were certain she was innocent. I knew they could be biased in their perceptions, but unless they were trained to know what I was looking for, they couldn’t easily manipulate my impressions.

I was looking for any symptoms of sexualization or cruelty in Amanda’s recent history. RAD doesn’t go away by itself, and it doesn’t improve with time. Instead, the symptoms digress. If Amanda had been cruel to animals early in life, she almost certainly would not stop, and the cruel behavior would escalate. Likewise, if she truly was a child with RAD and she had acted out sexually early on, she would still be engaging in sexual behaviors, and those behaviors also would have escalated. Cruelty moves through a digression — objects to animals and then animals to people. Sexual behaviors digress as well — masturbation, sexual exploration, acting out with consenting others and, finally, acting out on others by force.

Children might easily “practice” their sexual exploitation on animals before moving to humans because animals are easier to control. If Amanda had done something so overtly sexual and cruel to the two family pets, there would have to be symptoms of cruelty and sexualization in her recent history. But my interview with her parents turned up no such allegations in any context, at any time, from any teacher, playmate, sibling, coach or therapist.

I was also interested in Amanda’s ability to connect with other human beings — to show and receive affection. Children with RAD have trouble with both. The comments of the foster parents were consistent with what I had observed in my evaluation. Amanda had no troubles connecting in any context — school, church, athletics or home. She seemed to be a loving child who, although socially awkward, got along well with others and would not intentionally hurt anyone or anything.

I also needed the investigative perspective of the sheriff’s deputy, even though I knew he was already convinced that Amanda was to blame. For good reason, he saw no other logical suspect and had focused all of his investigative resources on her, but he was waiting for my evaluation before proceeding. He provided me with the basic facts of the case. During our first conversation, I derived a clearer picture of how this event could have taken place. The timing of events and other facts confirmed the information I had received from the foster parents. This confirmation was very important because it allowed me to dismiss the possibility that they were attempting to deceive me. It also helped me create a visual image of the event and give further consideration to how Amanda might have injured these dogs without being detected as well as how difficult that might have been for her to do.

Armed with that information, I realized it was at least possible that Amanda was just beginning to exhibit cruel behavior. I needed to know what the dogs experienced, so, with the consent of my client, I called the veterinarian who conducted the surgeries. My main question: Would someone have known she was hurting these animals, or would the animals simply have stood still and allowed the abuse? After all, Amanda was tiny, and these were large, full-grown dogs. Could she have restrained them?

The vet said the dogs would have been howling, struggling and whimpering. “No question,” he said. “The perpetrator would have known these dogs were in serious pain.” This was consistent with the idea of children with RAD intending to do harm, but it left me wondering how Amanda could have controlled the dogs long enough to do this.

I wanted a second opinion. I called a university with a respected veterinary program and talked to the department chair. I sent him photographs of the objects used in the abuse and gave him a summary of the case. His answer to my question? The dogs would have simply stood there and accepted the abuse! The perpetrator may not have known that he or she was causing serious, life-threatening pain, he said. This could be consistent with a child just beginning to act out on animals and didn’t exonerate Amanda.

I now had two completely opposing opinions, so what could I do? I chose to dismiss the “pain” component because I couldn’t be certain which veterinarian to believe. What was uncontested was the fact that both female dogs had large objects inserted into their vaginas. This was clearly a sexual behavior. Most adults couldn’t even find a dog’s vagina. The most obvious rear orifice in a female dog is the anus. This told me that this perpetrator had to deliberately seek out the vagina. Therefore, this was almost certainly not the first time he or she had acted out sexually, which was inconsistent with Amanda’s history. Was it possible for a child to go from simple “show me yours” sexual acting out nine years earlier to vaginally violating not one but two animals at the same time? I hardly saw that as possible.

 

Conclusions

After nearly two weeks of study, interviews, telephone calls and assessments, my final conclusion was that Amanda had nothing to do with the abuse to these animals. I believed that the loving and caring foster family had helped her weather a very difficult start to her life and their interventions had been effective in counteracting the problems of early attachment issues. Amanda measured low normal in IQ, and it seemed inconceivable to me that she could be cunning enough to hide this type of serious dysfunction from everyone in her environment for so long. Although it wasn’t impossible, it was highly improbable.

It was my recommendation that the foster care agency carefully investigate other possible perpetrators among the children in the home and that the sheriff’s department look into other possible suspects from nearby homes as well as hunters or others who might be known to be in this remote area. In my final telephone call with the investigating officer from the sheriff’s department, he asked me the obvious question: “If this child didn’t do it, then who did?” Occam’s razor tells us that the simplest solution is most often the correct one. That just wasn’t the case here. I didn’t want to sound trite, but the person he should investigate really wasn’t my problem, and I said so, although not so bluntly.

Still, I remained tentative in my final evaluation. The risk to others was very high if I was wrong. Therefore, I proposed that Amanda be reevaluated at six months, and I also recommended that she be evaluated by an expert in dissociative identity disorder (DID). The only way I could fathom her possibly committing such acts and yet successfully hiding them from everyone for so long was the remote possibility of DID. I suggested that either I was right and Amanda had nothing to do with this incident, or I was wrong and she was the most clever, sly and dangerous child I had ever seen in my practice.

So, why couldn’t I have simply skipped all the phone calls and gone with my initial evaluation? After all, it appears that I was correct, wasn’t I? Yes, but a possibility certainly existed that I was wrong, and the risk that posed to Amanda, her family, animals in her environment and others was scary. If I had concluded that Amanda was not the perpetrator and was wrong, she would have been free to act out on other animals. In addition, this behavior was so cruel that it would have been a very small step for her to act out on humans, including younger or weaker siblings or playmates. She would have been a risk to everyone she came into contact with.

On the other hand, if I concluded that Amanda did in fact commit this act, she would have been removed from the home. She had lived in this stable, loving home for most of her life, and if my conclusions were wrong, she would have been unfairly uprooted, stigmatized and very difficult to place in the foster care system. The progress she had made might quickly have been undone, and my mistake could have had lifelong consequences for her. Both of these possible outcomes had serious consequences.

 

Follow-up

One year later, my conclusions seem to have been proved correct. The follow-up for DID resulted in no indication of multiple personalities, and the psychologist’s conclusions were the same as mine. Subsequent evaluations also rendered conclusions consistent with my original evaluation, and no other incidents have occurred in the family home or environs. To my knowledge, no other perpetrator has been pursued or apprehended.

This case presents four very important lessons for counselors:

1) Cover every base. Avoid the temptation to lean too heavily on any single piece of information or assessment for conclusions. Assessment processes, interviews, case material and other sources of information can provide triangulation and help confirm or disconfirm information that might be presented in a child’s file.

2) Material in case files may not be objective, and there may be other ways to see the behaviors recorded therein. Read these files with objectivity and caution.

3) Be tentative in your conclusions.

4) Follow up for certainty. If I had been wrong in this case, my recommended follow-up could literally have saved someone’s life.

 

 

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Gregory K. Moffatt is a professor of counseling and human services at Point University. A licensed professional counselor, he has more than 25 years of clinical experience treating trauma with children. Contact him at Greg.Moffatt@point.edu.

 

The connection between ADHD, speech delays, motor skill delays, sensory processing disorders and sleep issues

By Donna Mac January 16, 2015

To ensure the overall well-being of child clients with attention-deficit/hyperactivity disorder (ADHD), counselors frequently work in combination with other service providers such as speech therapists, physical therapists, occupational therapists and sleep specialists. According to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), many children with ADHD have also ADHD2experienced speech delays, gross motor delays and fine motor delays. In addition, many clients with ADHD showcase sensory issues or have a comorbid sensory processing disorder. Many children with ADHD seemingly also struggle to settle down at night, especially when parents are trying to get them into bed.

What is the connection between ADHD and these other deficits? If we take a look at the structural and chemical makeup of the ADHD brain, we find similarities with these other areas. First, let’s take a look at what an ADHD brain can look like:

  • There can be a smaller frontal lobe with less blood flow to it. This is where the executive functions exist: planning, organization, task initiation, task completion, time estimation, time management, self-regulation, social behavior, short-term memory, working memory, motivation, impulse control, intentionality, purposefulness and the ability to transition effectively. A smaller frontal lobe will lead to emotional immaturity.
  • The overall cerebral volume is usually smaller as well.
  • The neurotransmitter systems of dopamine and norepinephrine are affected. People with ADHD do not produce enough, retain enough or transport these neurotransmitters efficiently through the brain. MRI studies show that this inefficiency can be due to less white matter and more grey matter in the brains of clients with ADHD, which slows transportation. Dopamine is the main “focus neurotransmitter,” heavily associated with the frontal lobe and the executive functions, in addition to being the “feel good” neurotransmitter. It is also heavily linked to the limbic system, which contributes to people with ADHD reacting in a manner that is disproportionate to the event, either positively or negatively. Norepinephrine is involved in focusing on tasks a person considers to be either boring or challenging. In addition, it plays a role in sleep.
  • These clients can have a smaller caudate nucleus with less blood flow to it. The caudate is heavily innervated by dopamine neurons, and it plays an important role in learning, memory, social behavior, voluntary movement and sleep.
  • Electroencephalograms (EEGs) have shown that people with ADHD have more slow waves (theta waves) present than the general population when they are in an “awake state.” The increase in slow waves is especially pronounced during reading and listening tasks, causing people to lose focus, daydream or become drowsy.

All of this simply means that the ADHD brain is less mature and has less activity than a neurotypical brain. It is important to note that a doctor will not order an EEG or MRI either to diagnose or rule out ADHD because these findings are not indicative only of ADHD. In fact, many other issues present this way, including the following.

Speech delays: As stated earlier, the frontal lobe plays a key role in ADHD, but it also plays a role in speech production. There is a significant distinction between those with ADHD who have had speech and language delays versus the general population. It is also important to understand that children with speech and language delays typically have attention spans commiserate to where they are developmentally with language. For instance, if a 7-year-old speaks at a 4-year-old level, the child’s attention span may be that of a 4-year-old. This does not mean the child has ADHD. In addition, the child with a speech delay might find it challenging to communicate needs appropriately, so the child may begin to act out, have tantrums or melt down, much as a child with ADHD might demonstrate. Therefore, if a child has a speech and language delay, a thorough investigation needs to be conducted to determine whether the child’s “ADHD types of struggles” (of both attention and behavior) are related to the language delay, or if, in fact, the child also has ADHD.

If a child does have both ADHD and a speech delay, a physical therapist can make recommendations to the speech therapist concerning how to use specific large-body movements during speech therapy sessions. This will bring blood and glucose to the frontal lobe of the brain. This can be beneficial for speech production and will help the child with ADHD to feel more emotionally regulated.

Another speech issue connected with ADHD is speaking too quickly. This will sound almost as if the child’s speech is slurred. This can be due to the cognitive impulsivity related to ADHD. It can be addressed in a psychotherapy session or a speech session by having the child draw slow, wavy lines as the child speaks.

Motor skill delays: The ADHD brain processes slower than a neurotypical brain because of the transportation difficulties with the neurotransmitters and also because of the increase in slow wave (theta wave) movement. Interestingly enough, researchers find that about half of all children with developmental gross motor coordination disorders actually suffer from varying degrees of ADHD.

Why? Possibly because slower brain processing speed is also manifested in motor skill deficiencies. These motor delays are helped by physical therapists. However, there are other techniques used as well because there are activities that can help speed processing in the brain, such as balance-based activities. Physical therapists and occupational therapists tend to work together to incorporate balance-based activities with both motor skill delays and ADHD because the act of balancing the body actually requires the use of both hemispheres of the brain. In turn, this speeds processing, increases focus and decreases impulsivity.

Other extracurricular activities such as gymnastics, yoga and martial arts involve balance and practicing controlled movement, which are crucial for both ADHD and motor skill deficiencies. Some children with ADHD will have difficulty with fine motor issues such as buttoning clothing or tying shoes, and occupational therapists can help with those concerns as well.ADHD1

Sensory processing disorders: Reward-deficiency syndrome is when the brain is asking for more dopamine. This can be witnessed in the hyperactive response of those with ADHD when they “sensory seek” (spinning around and around, for example) or “novelty seek” (such as hanging over a two-story banister). Dopamine also limits and selects the sensory information that arrives to the frontal lobe, which is one reason that children with ADHD show these sensory issues. In addition, there is a less developed frontal lobe in cases of ADHD. This poses a “double whammy” because both dopamine and frontal lobe issues are involved with sensory concerns as well.

An actual sensory processing disorder occurs when a person has difficulty with the way the brain senses, organizes and utilizes sensory input. This results in unexpected outcomes of movement, emotions, attention and adaptive behaviors. It is as if the brain is using unexpected information on the way in, so, naturally, the unexpected emotions and behaviors come out, which can create further stress and anxiety for the person. Some people with ADHD will have certain sensory concerns without having a full-blown sensory processing disorder, but other people will have both ADHD and a sensory processing disorder. Occupational therapists are skilled at helping children with these issues.

Sleep issues: Children with actual sleep disorders or inconsistent sleep patterns will showcase symptoms similar to ADHD such as irritability, less developed social skills, attention difficulties, memory impairment, lower academic output, increased internalizing and externalizing of problems, not complying with requests and aggression. Because of this particular symptomology, it is crucial to rule out a sleep disorder before diagnosing ADHD.

Can a person have both ADHD and difficulty sleeping? Yes, but not always. A study was published in The New York Times in which researchers focused on children with comorbid diagnoses of ADHD and a sleep disorder. A year after surgeries or treatments for the sleep disorders, only half of the children retained their ADHD diagnosis, meaning that the other half had been misdiagnosed with ADHD; it was only the sleep disorder causing their symptoms.

It’s important to note that “trouble sleeping” was once a symptom qualifier to secure an ADHD diagnosis. The symptom was removed from the DSM in 1987, but the issue can still occur with some people. Remember that the caudate nucleus and norepinephrine are involved in both ADHD and in sleep, which is one reason people may struggle to sleep some nights. Most children with ADHD tend to have difficulty settling down at night and getting into bed because of their hyperactivity and impulsivity, which can spike in the evening hours. But once in bed and calmed down, children with ADHD can usually fall asleep in a time frame that is considered “within normal limits.” Many children with ADHD tend to wake quickly and experience an accelerated start to their day.

 

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Donna Mac has worked professionally with ADHD for 15 years as a teacher, a YMCA director and currently as a licensed clinical professional counselor in a therapeutic day school. She is also the mother of twins diagnosed with ADHD at age 3. She has published a book titled Toddlers & ADHD, available on Amazon.com, BarnesandNoble.com, Balboapress.com and at her website: toddlersandadhd.com.

 

Going wild

By Bethany Bray December 23, 2014

In a matter of months, 16-year-old “David” had gone from being a successful student to spending 12 or more hours per day playing video games. He lost his scholarship to a private school, then dropped Branding-Box-Utah-streamout of school altogether, refusing to leave the couch, even to bathe.

He also stopped communicating with his family. His parents, with whom David had previously been affectionate and close, were afraid he was shutting down.

Diagnosed with depression, David saw four different mental health professionals without making much progress. What finally reached David was wilderness therapy, a unique treatment model that brings clients to natural settings for intensive therapy with a counselor (or other mental health professional) and peer group.

David spent 12 weeks in a program in the high desert plateaus of southern Utah. Although initially resistant to the program, the wilderness setting and peer group eventually prompted him to become social again and work through his struggles. David and his parents exchanged letters while he was away, helping to repair the relationship.

Now back at home, David is again close with his family and flourishing at school. In fact, he was recently elected student body president, says Steven DeMille, an American Counseling Association member who was David’s counselor at Redcliff Ascent, a wilderness therapy program in Utah.

In a post-therapy case study, DeMille, a licensed clinical mental health counselor who is a clinician and director of research at Redcliff Ascent, wrote, “The wilderness provided David with a challenging, straightforward and neutral environment to reflect on old behaviors and try out new options. … David realized that he no longer needed to defeat the structure through disengagement to meet his personal needs. He could meet his needs through following rules and meeting social and family expectations.”

Redcliff Ascent is one of a growing number of programs across the United States that specialize in wilderness therapy. Although models vary from program to program, the majority involve taking groups of clients — most commonly youth or young adults — out into the wilderness for an extended period of time. Participants, including program staff, typically sleep outside, pitch tents, hike and cook food over an open fire.

Therapy occurs in both group and one-on-one sessions. But it also takes place “in the moment,” such as when a client’s anxiety flares when struggling to start a fire or self-doubt kicks in when tasked with leading a hike by compass, says Sean Roberts, a clinical mental health counselor who has worked in wilderness therapy for almost a decade.

“The wilderness is such a powerful intervention because it’s unpredictable,” adds Sabrina Marie Hadeed, an ACA member and licensed professional counselor at Second Nature Cascades, a wilderness therapy program in Oregon.

In one case, a client of Hadeed’s was struggling to set up the tarp for her sleep shelter during an unexpected rainstorm. Frustrated to the point of tears, she gave up and sat down in the rain. The situation served as a chance for Hadeed to talk with the client about coping when circumstances were out of her control and how to ask others for help, both of which were hard for the young woman.

“There’s equal balance in the wilderness of challenge and nurturing, structure and safety, and really learning what’s inside and outside of your control,” says Hadeed, who is finishing her doctorate in counselor education and supervision at Oregon State University. “It’s challenging [for clients] to lean into the discomfort of their difficult feelings rather than turn from them. As long as it’s safe, we’ll encourage them to do that [and they] will increase tolerance for those feelings. In a traditional setting, you meet with a therapist for an hour, even if it’s twice a week. You leave that space and you don’t have to practice what you’ve practiced in the session. In the wilderness, you have to practice all the time — how to give feedback, express frustration, interact with peers.”

Simply put, wilderness therapy is evidence-based therapy — including traditional methods such as Adlerian therapy, cognitive behavior therapy and others — that is done outdoors, say Roberts and DeMille, who presented together on the topic at the 2014 ACA Conference & Expo in Honolulu.

The wilderness therapy model is intensive in many ways, from the group dynamics and 24/7 interaction with program staff to the often breathtaking scenery and natural challenges confronting the clients. Practitioners in the field say wilderness therapy has been proved to have positive outcomes for clients, from better management of behavioral disorders, anxiety, addictions and other struggles to boosts in self-confidence and overall health, including nutrition and sleep patterns.

“The therapy is much more challenging than anything physical,” says Roberts, an ACA member who just began a position as clinical director at Cascade Crest Transitions, a residential program for young adults in Bend, Oregon. “It creates a very powerful milieu. … It’s an incredibly rich and fertile environment for therapy [and] a strengths-based approach to healing.”

Outdoor behavioral health care

DeMille prefers to use the term outdoor behavioral health care rather than wilderness therapy because he says the latter is a nebulous, unregulated term that many nonprofessionals use. He recommends that counselors looking to refer clients search for programs that adhere to the outdoor behavioral health care model, which is a regulated industry with set standards (see sidebar on the Outdoor Behavioral Healthcare Council below).

“There are going to be programs out there that say they’re wilderness therapy, but that’s not necessarily outdoor behavioral health care,” DeMille says.

Outdoor behavioral health care is light years away from the “boot camp” image that many people still associate with wilderness therapy programs, where participants are “broken down” in order to build them back up, Roberts and DeMille say. In fact, outdoor behavioral health care is the opposite, says DeMille.

Regulated programs, including all of the programs for which the counselors interviewed for this article work, have field guides with small groups of clients around the clock. Although the guides are not counselors or mental health professionals, they are given extensive training in wilderness living and serve as adult mentors to clients. Client groups range in size from a few individuals to a dozen people.

Clients meet regularly with a counselor or other licensed mental health professional from the program’s support staff. These counselors work closely with the field guides to get feedback and check in on the client’s progress concerning the treatment plan or goals.

Counselors lead group and individual therapy sessions, work on outreach to families and provide case management. As a clinical director, Roberts says he will also join a group at least once per session for an overnight trip outdoors. He remains on call whenever he isn’t with the group.

“There’s so much more to work with than when I’ve done outpatient work and so many more ways to gather [client] data,” Roberts says.

Clients enter outdoor behavioral health care programs for a number of reasons, including treatment for a variety of mental health diagnoses, behavioral problems, substance abuse issues, problems with school or relationships and trauma recovery. Client stays are usually open-ended; they leave the program only when they are ready, Roberts says. An average stay at DeMille’s program is 70 days, whereas the average at Hadeed’s program is eight to 10 weeks. Programs have rolling admissions, with clients joining and leaving the group intermittently.

Parents of youth clients stay involved with the program and visit their sons or daughters in the wilderness, even sleeping overnight. Hadeed’s program maintains a website for clients’ families where they can post photos and updates and exchange messages while their teenager is out in the wilderness.

Prior to discharge, counselors spend a significant amount of time preparing clients for re-entry into home settings or social situations that previously caused them distress or with which they had difficulties. This process includes working to hone the client’s decision-making and communication skills, relapse-prevention strategies and other coping methods, DeMille says.

In addition, outdoor behavioral health care therapists often work with school staff, counselors and other helping professionals in the client’s hometown to ease the transition. “We do put a lot of energy into figuring out what will set them up for success as they leave,” Roberts says.

The right fit

Outdoor behavioral health care is often effective for clients who are “stuck or deteriorating in treatment” or not responding to traditional therapy methods, according to DeMille. It can also be a good fit for those who drop out of traditional talk therapy or end up hospitalized after a suicide attempt or overdose.

The approach is also effective, says Roberts, with clients who are struggling with a “failure to launch”: young adults who are underperforming in life or career, including failing or being kicked out of school or college.

Roberts, who is finishing his doctorate in counselor education and supervision at Oregon State University, previously worked at Second Nature Entrada, an outdoor behavioral health care program in southern Utah, near Zion National Park. He notes that many of his clients have “been through tons of talk therapy” but struggled to put what they learned into practice. Many have legal records, family systems issues, depression, a history of suicide attempts or struggles with self-medication via substance abuse. These clients are often wrestling with dysfunctional relationships, destructive life patterns or an internalized sense of hopelessness, he says.

“They need an opportunity to unplug from that [life] and course correct — shift the trajectory of where they’re heading … stabilize and gain some tools to increase their confidence,” Roberts says.

Counselors interviewed for this article agreed that outdoor behavioral health care can be a good fit for clients who struggle with:

  • Self-harm
  • Low self-esteem
  • Poor body image
  • Depression
  • Emotional, mood or anxiety disorders
  • Developmental disorders, including attention-deficit/hyperactivity disorder
  • Trauma
  • Behavioral disorders
  • Substance abuse
  • Poor school performance
  • Being disruptive, uncooperative or withdrawn
  • Having poor boundary issues with peers (such as crush obsessions or sexting)

Conversely, outdoor behavioral health care is not recommended for clients with:

  • Severe eating disorders
  • Severe forms of autism
  • Learning disabilities that cause them to become oversensitized easily
  • Psychotic disorders such as schizophrenia
  • Medical conditions that necessitate being near a hospital (for example, diabetes)

Being comfortable with the outdoors is not a client prerequisite, Hadeed emphasizes. In fact, taking clients out of their comfort zones — and away from their cell phones, friends and favorite TV shows — is often a factor in their healing and progress.

Hadeed says counselors considering whether to refer a client to an outdoor behavioral health care program should first speak with program staff to determine if the client might be a good fit. Conversely, if a counselor is working with a client who has already gone through an outdoor behavioral health care program, the counselor shouldn’t hesitate to reach out to program staff to collaborate, she says.

“Whether it has been one year or five years, the experience will still be with [the wilderness therapist], and they can talk through what works [for that client],” Hadeed says. “That collaborative piece is really important.”

A journey of self-discovery

Gil Hallows, executive director of Legacy Outdoor Adventures in Utah and chair of the Outdoor Behavioral Healthcare Council, calls the outdoor behavioral health care model a “modern-day rite of passage.” He draws comparisons with the Australian aboriginal “walkabout” and similar rites in other traditional cultures in which adolescents spend time in the wilderness to learn, grow and discover their strengths, returning to society as adults.

Similarly, outdoor behavioral health care is an “individualized journey of self-discovery,” says Hallows, who has worked in the field for two decades.

Hallows and the counselors interviewed for this article agree that numerous factors contribute to the modality’s success with clients, including:

Time away: Outdoor behavioral health care clients spend weeks away from home. In doing so, they are removed from the people, circumstances and other factors that may be contributing to their destructive behaviors and struggles with mental health, including friends, addictive substances and technology.

Hallows refers to this as “the great slowing” because clients have time to think more clearly and reflect on their life away from distractions. “It takes a young person away from everything they’re accustomed to manipulating,” from their own families to video games, he says.

In addition to long hikes, journaling time and other opportunities for self-reflection, some outdoor behavioral health care programs include a “solo” experience, in which clients spend time alone for introspection.

The time away from school cliques, name-brand clothes, cell phones and other familiarities often leads to breakthroughs in self-identity for clients, Hadeed says. In one case, a client discovered that her sense of humor and knack for performing could be a strength and a way to process and communicate her feelings rather than a means of getting her in trouble, as it had in the past.

Time away challenges clients to ask those important questions of identity, Hadeed says. “[It] highlights the strengths, gifts and natural positive qualities they have that they weren’t aware of because of the distractions of daily life, including technology,” she says.

Learning by doing: Part of the outdoor behavioral health care experience for clients is learning to take care of their own equipment, cook meals together and share in other chores such as gathering wood and building fires.

In most cases, clients are learning to do things they’ve never done before. Moments when clients struggle or get frustrated turn into opportunities for in-the-moment encouragement and guidance from program staff.

Roberts says this process leads to empowerment and taps into a host of skills that will carry over into everyday life, including dealing with frustration, sticking with a task, learning to ask for help and engaging in long-term planning.

“It’s almost unavoidable — clients will learn skills, [including] self-confidence, problem-solving, self-care and task accomplishment,” Hallows says. “It’s extremely fulfilling and rewarding to observe the transformation that takes place in a young person when they discover who they are and what they are capable of doing while on a wilderness journey.”

Roberts says he will suggest tasks for clients based on issues they are dealing with in their therapy sessions. He works with the field guides to set up interventions, such as the job of leading a hike by compass, to see how clients respond to specific challenges.

Roberts says he might also suggest that a client who is weighed down by emotional baggage (such as anger or a destructive behavior) take a walk while carrying a rock, a stick or some other object. Afterward, he will talk with the client about the metaphor of carrying something around with us constantly, why that is a challenge and how it can be overcome.

Participants in outdoor behavioral health care often gain new perspective, DeMille says. “Things that you have taken for granted [meals, for example], all of a sudden you have to work for,” he says. “It develops a sense of mastery, competency. They grow in confidence and competencies.”

The model also lends itself to learning what is and isn’t in your control, Hadeed says. “You can’t control the rain, the wind or the weather, but you have control over whether you’re going to put on a jacket or build a fire, and that can be translated to a family setting,” she says. “You can’t control what mood your dad is in when he comes home, but you can control your response to that mood.”

Group dynamic: In most cases, clients in outdoor behavioral health care programs join a group of people they’ve never met before. Over time, the client bonds with group members and staff leaders, Hallows says.

“Sharing a common experience with a group of peers and staff, it lends itself to establishing a tight peer group that holds each other accountable,” he says. “They learn to identify and express emotion, become honest with themselves. And if they’re not, they’ll be called out by their peers.”

Clients work through anxieties and other issues alongside one another, learning as they go. The shared experience with people who are trying to overcome similar struggles is the opposite of the isolation of one-on-one therapy in an office, DeMille points out.

“The group dynamic allows [clients] to work on problems in conjunction with peers in their group,” he says.

The around-the-clock guidance from field staff is also a factor, agree DeMille and Hallows. Clients benefit from seeing adult mentor figures working alongside them, completing hikes, setting up camp

Clinical mental health counselor Sean Roberts provided this photo  of his previous “office” in the wilderness northwest of Enterprise, Utah.

Clinical mental health counselor Sean Roberts provided this photo
of his “office” in the wilderness northwest of Enterprise, Utah.

and sharing meals, chores and other tasks. These field staff work closely with the program counselors to make sure that clients are on the right track and meeting treatment goals.

Hadeed notes that many of her clients come into the program with a misconception of what therapy is or should be. She explains to them that there’s more to therapy than feeling good; therapy presents both challenges and rewards.

“[Therapy] is not always about helping you to feel happy but rather learning to tolerate very normal feelings — worry, fear, anxiety,” she says. “It’s helping you to learn how to tolerate and better express those feelings, ask for help and if you feel like crying, crying. We help them learn that these emotions they are feeling are totally normal, and the more you try and contain them, the more they’re going to come out in other ways.”

The natural setting: Lastly, the natural environment lends itself to lessons of growth and healing. Many outdoor behavioral health care programs take groups into national parks and other breathtaking locales.

“There’s something healing about being outside,” Hallows says. “A good counselor … finds the wilderness setting a huge ally. [For example], counseling a person who has survived a rainy night, kept himself dry and started a fire. Compare [those skills and victories] to his or her life before. … Imagine how impactful one can be as a counselor if you have that experience and setting as an ally. The experience of living outdoors and living in a group of peers, those are the change agents, and if you add counseling to that, you’re leveraging the experience.”

Bringing the outdoors in

The counselors interviewed for this article agree that some of the elements that make outdoor behavioral health care successful can be introduced in more traditional office settings as well. For example, group therapy and hands-on experiential exercises will be more effective at reaching certain clients, Roberts says.

In addition, instead of talking with clients about what happened yesterday, consider working through challenges “in the here and now,” he says. “Give [the client] a task to do. Put together a puzzle [or do] something that is going to create some anxiety, a chance for failure — whatever fits for the client.”

As in outdoor behavioral health care, traditional counselors can also include discussions about overall health, including exercise, nutrition and sleep habits, Roberts says. In addition, both DeMille and Roberts recommend getting outside with clients during counseling sessions when appropriate, such as by taking walks. Furthermore, they say, counselors can prescribe clients to take walks or get outside more on their own.

Parents sometimes turn to outdoor behavioral health care as a last resort, an 11th-hour option after going through multiple therapists or programs, Hadeed says. She’d love to see the opposite: wilderness therapy as a family’s first option.

When most people think of counseling, they picture an office and the iconic leather couch. Instead, what if they pictured a mountainside group therapy session or a counselor chatting with a client as they hiked or went fishing?

“That would be my dream,” Hadeed says.

Wilderness-authors

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The freedom and light heart I deserve

The following prayer was written by 19-year-old Skye Angelo Rossman, a former client at Second Nature wilderness therapy.

“In my life, I have experienced much love and much hate. I did not enjoy the severity of the extremity. From this day forth, I ask to eliminate the one that doesn’t allow me the freedom and light heart I deserve. I have been through much and will go through much more. It is my hope that I am given the respect I give you in my life. It is with eternal gratitude I pray, amen.”

— Reprinted with permission from Sean Roberts and Skye Angelo Rossman 

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The Outdoor Behavioral Healthcare Council: Collecting data, carving out a niche

In the early 1990s, what little knowledge most Americans had of wilderness therapy came via news headlines when something went wrong at a program, including, tragically, a handful of fatalities.

The decade had witnessed a marked increase in the number of programs launched, says Gil Hallows, chair of the Outdoor Behavioral Healthcare Council. However, he says, wilderness therapy programs were operating independently, without a distinct sense of mission or best practices.

With this in mind, representatives from five wilderness therapy programs came together in spring 1996 with the aim of solidifying the field of wilderness therapy. They called themselves the Outdoor Behavioral Healthcare Council. In addition to establishing best practices, the group began collecting data to document, verify and maximize the effectiveness of the wilderness therapy treatment model, Hallows says.

“It became clear that organizing would allow us to set some standards [and] allow us to better work together in educating the public on what we do and how we do it. … We wanted to focus on doing this the right way,” says Hallows, who also serves as executive director of Legacy Outdoor Adventures, a wilderness therapy program in Utah.

Most recently, the council partnered with the Association for Experiential Education to develop a set of accreditation standards specific to wilderness therapy programs. The council adopted the accreditation model in early 2014. Member programs must now become accredited within two years of joining the Outdoor Behavioral Healthcare Council.

Close to 20 years after its founding, the Outdoor Behavioral Healthcare Council has 17 member programs, plus two others currently going through the application process. The council hosts an annual symposium, held this past year in Park City, Utah, with education sessions and networking opportunities for professionals in the field.

More than 15 years’ worth of the group’s research — from statistics on program safety to client substance abuse pre- and post-participation — is available to the public through the council’s website (see OBHcouncil.com).

To become a member of the council, a program must collect data regularly for the council’s research mission. Members typically record data points about clients’ mental and overall health at intake, discharge and six months after being discharged from a program, Hallows says.

Statistics on the effectiveness of wilderness therapy, especially its cost effectiveness, are fueling the council’s campaign to improve insurance coverage of outdoor behavioral health care. Historically, insurance companies have been reluctant to reimburse clients for costs incurred for participation in wilderness therapy programs, Hallows says.

The Outdoor Behavioral Healthcare Council is reaching out to insurance companies and providing data on wilderness therapy’s effectiveness in hopes of changing that scenario. The group also provides resources to help guide clients’ families through the appeal of a claim denial, Hallows says.

“Part of this campaign is to make outdoor behavioral health care more available to average families,” he says.

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Related reading

  • Sabrina Marie Hadeed’s piece “Girls daring greatly,” a first-person perspective of how wilderness therapy can reach and help adolescent girls
  • Wilderness therapy: The question of affordability,” a look at the cost of wilderness therapy programs and the steps the Outdoor Behavioral Healthcare Council is taking to make them more affordable for average families

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

Letters to the editorct@counseling.org

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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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