Tag Archives: Children & Adolescents

Partnerships and urban youth

By Amie Tat and Rebecca L. Toporek June 25, 2014

urban“Michael Taurus” is a C student who, as a ninth-grader, gave very little thought to his options after high school. If pressed, he probably would have mentioned going to community college or getting a job. Michael’s parents immigrated to the United States shortly after he was born and did not have the opportunity to continue their education beyond elementary school. Michael’s father struggled with job security, working odd construction jobs whenever they were available, while Michael’s mother worked the graveyard shift, cleaning hotel rooms to help support their family of six. Michael, the eldest of four children, spent most of his time after school taking care of his younger siblings in his parents’ absence.

According to a 2012 report from the National Center for Education Statistics, gaps across almost all measures of achievement and persistence in education are greatest for children living with poverty, children who are English language learners and children from ethnic minority groups most represented in low-income urban communities. Urban youth often have difficulty envisioning and investing in their futures fully due to other circumstances that require more immediate attention. For example, students worried that their families will be evicted from their homes may have difficulty focusing their attention on applying to colleges or preparing for employment.

The current state of the education system and the challenges that urban youth face affect the way that all counselors, not just college and school counselors, work with individuals, schools and communities. In short, systems-level solutions and partnerships are needed. This article explores issues confronting urban youth and describes one example of an equity-based partnership designed to promote a “college-going culture” in underresourced urban high schools. This effort is cultivated through the development and maintenance of community, school and higher education partnerships.

Consistent with scholarly definitions of urban youth, we are referring to young people, mostly ethnic minority, who reside in densely populated, lower socioeconomic, inner-city neighborhoods. A combination of internal and external challenges affect the ability of urban youth to succeed academically and become self-sufficient adults. Common environmental challenges include lack of adequate resources, limited access to social services and communities stricken by the influence of drugs and alcohol, violence and poverty.

The transition to college requires more than just academic preparation. Urban youth face motivational barriers and bleak expectations of their potential for college due to a lack of positive or knowledgeable role models who demonstrate academic success. In addition, many community members in urban neighborhoods struggle financially to support their families. Children are often expected to assume greater responsibility within the household or work outside the home to help support the family. Managing these obligations often interferes with students’ ability to perform well academically. Furthermore, their families’ lack of monetary resources and limited knowledge of financial aid can influence urban students’ attitudes toward higher education because the importance of earning money to help support their families is more urgent than spending money to go to school. Given the immediate financial needs for survival, the long-term investment of school is costly, both in terms of the funds needed to attend school and the delayed earning of wages. These circumstances lead many urban youth to become disengaged academically and less likely to pursue higher education.

Nevertheless, many urban families do their best to support their children’s educational efforts despite the challenges to financial stability and their limited knowledge of preparing for and navigating the transition to college. Making comprehensive support systems available to these families early in the high school experience can help address these difficulties and encourage urban youth to proceed in a positive direction.

Formal structures such as schools are expected to provide knowledge and skills for successful adulthood transition, either through higher education or employment. But in school systems with inadequate resources and overwhelmed staff, the school’s potential to have a direct impact on its students’ successful transition to college is disrupted. This is further intensified when schools lack a strong college-going culture.

Many urban high schools face significant behavioral and social challenges, such as community violence, conflict within the school and the influence of crime and gangs on the school community. These factors frequently require school administrators, counselors and teachers to focus on discipline and safety issues. Consequently, more effort is placed on addressing delinquent behavior than on promoting student achievement. Inadequate resources also hinder a school’s ability to expose students to higher education settings through field trips to college campuses and other activities. Because the influences and needs of students are so complex, a comprehensive partnership approach is indispensable.

A study of partnerships

System-level solutions are required to address the complex challenges faced by urban communities. For example, one of the major ongoing issues in underresourced urban schools is inadequate staffing due to tumultuous public funding issues. Frequent turnover among administrators, teachers and counselors inhibits the systematic ways schools can prepare students for postsecondary institutions. Changes in leadership create inconsistencies within the many structures of the school.

Partnerships that involve organizations committed to maintaining an ongoing and visible presence at the school can help establish and maintain stable relationships with students despite fluctuations in public funding. Sustained relationships with the community also contribute to greater cultural understanding of the students and their families. Counselors who develop and maintain their multicultural competence and advocacy competence as well as their skills in facilitating group systems are a tremendous resource, both within the school and the community.

A fundamental condition of creating a college-going culture and fostering successful transition to adulthood involves getting students to see themselves as having the potential to attend college or secure employment successfully. Counselors, school staff, agency staff and community members can work together so that students become aware early on of college and career counseling interventions. Students can then continue to connect with staff throughout various events and milestones in the process. Each of these partners contributes to greater understanding of the challenges faced by urban youth, the cultural values and styles of communication they revere and the strengths these students and their families present. Agency and school staff members who are bilingual and culturally competent are especially important in this environment to ensure that communication with families is clear and welcoming. Each partner also contributes to a more seamless functioning of a system that expects the best from students and conveys a belief in their success.

Developing initial and ongoing partnerships

This article focuses on the partnership between Seven Tepees Youth Program and John O’Connell High School (JOCHS) in San Francisco. The College and Career Centers of the Seven Tepees Youth Program are equity-based programs launched in 2007 to promote a college-going culture in two urban high schools through the development and maintenance of community, school and higher education partnerships.

The parent organization, Seven Tepees, was established in 1995 as a nonprofit organization in San Francisco’s Mission District. (The name Seven Tepees was given by one of the organization’s founders, Native American healer Hully Fetiçó. The name represents the diversity of the seven continents and the Native American tradition of connection to nature and care of the land. Although the program does not primarily serve Native American students, the richness of the world’s cultures is an integral part of all program components.) The organization works with urban youth to foster the skills needed to make lifelong positive choices and to create their own opportunities for success.

The primary mission of the College and Career Centers is to increase the number of students who enroll in college from the partner high schools and to work with these students to cultivate the skills necessary to transition to successful adulthood. The program serves all students regardless of GPA. The needs of the partner schools and communities, along with the alarming state of education, led Seven Tepees to recognize that systems-level solutions and partnerships were necessary for student success.

JOCHS, also located in the Mission District, was identified as an underperforming school by the state of California and mandated to undergo transformation. To provide some context, according to the San Francisco Unified School District School Accountability Report Card (2012), of the 471 students at JOCHS in 2011-2012, 58.2 percent identified as Latino, 15.9 percent as African American, 11.7 percent as Asian or Asian American, 7.4 percent as Filipino, 3.6 as white, 0.8 percent as American Indian or Alaska Native and 0.8 percent as multiracial. Moreover, 76.6 percent of the student population was identified as socioeconomically disadvantaged, 49 percent of the students were English language learners and 17.4 percent were identified as having disabilities. In addition, the continuity of school staff at JOCHS has been greatly challenged during the past decade, with 25 deans and administrators coming and going during that time.

Youth-proudly-raise-their-scholarship-letters-to-City-College-of-San-Francisco

Students proudly show their scholarship letters to City College of San Francisco.

From the time students enter JOCHS, they are exposed to the College and Career Center because of its central location on the high school campus. Student assistants work in the center, further contributing to its atmosphere as a hub of excitement and activity. These students also increase awareness of the center and of college as a real option through their existing social networks within the school. In this way, students begin to feel as though they belong in this space.

Exposure to the College and Career Center is enhanced with outreach to students early in their high school years. Then, during the middle of the 11th-grade year, a staff member from the center initiates the first formal individual meeting to discuss each student’s postsecondary goals. For some students, these goals may reflect a desire to enter the workforce rather than pursue postsecondary education. Regardless, the College and Career Center staff determines eligibility for college admissions for all students and facilitates a discussion of goals with each individual student. Prior to these meetings, some students favor employment over postsecondary plans due solely to the assumption that they would not be accepted to attend college or would be unable to pay for college. When provided with concrete information regarding possible resources, they are better able to examine their options fully and share information with their families to begin making decisions.

To meet with students individually, school partnerships and systems work cooperatively. For example, partnerships must be established with the teaching staff to create and implement procedures for supporting college-going culture goals, including releasing students from class for their individual appointments with the College and Career Center. An atmosphere of teamwork and trust is required so that school staff will approach this as a collaborative effort and treat it with the same importance as their curriculum. The College and Career Center must convey the connection between establishing a college-going culture and the need to meet with students individually. College and Career Center staff must also be strategic in seeking noninstructional times to meet with students — for example, during homeroom, lunchtime, free periods and after school — to keep disruptions to their academic courses to a minimum. If disrupting class time is unavoidable, the next task becomes determining which teachers are amenable to dismissing students from class. This process can be a challenge unless school personnel feel the goal is mutual. It is essential to have open and regular conversations with all partners regarding their perspectives on the value of transition goals, inclusive of vocational training as well as college.

The extent to which school counselors are directly involved in career and college counseling varies by district and state. This is often related to resources as well as policymakers’ visions of the role of school counselors. In urban schools, the ratio of counselors to students is often so low that counselors are stretched thin just handling safety and crisis concerns, basic course scheduling responsibilities and other administrative duties. But even in districts or schools where school counselors are unable to be directly involved in college readiness activities, they can still contribute to the process. School counselors may have existing relationships with students and families, knowledge of student histories, insights for working with students with specific needs or simply access to student records such as class schedules and academic transcripts. On a very basic level, school counselors can adjust student schedules to reflect the courses needed for graduation and college eligibility. Mutual sharing of information is essential as students are encouraged to set and reach milestones.

Other major partners within schools include school wellness centers and afterschool programs. In urban schools, these programs are often provided by community-based organizations (CBOs). Each of these partners expands the net of support for urban youth through mental health counseling, nutrition education, connection to social services, tutoring services, enrichment courses and credit recovery options. Students who receive such services may have a large network of therapists, tutors, mentors, case managers and social workers working collectively to ensure students’ overall well-being.

Developing and, most importantly, maintaining these partnerships with other departments and CBOs within the school becomes integral to helping students transition successfully into adulthood. For example, the Wellness Center and the College and Career Center at JOCHS often collaborate to provide workshops that address concerns such as anxiety or conflicts in the family about moving away for college. Additionally, a partnership with the school’s After School Program allows College and Career Center staff to work with tutors to ensure that students are on track for graduation and completing courses for college admissions. Other CBOs that may offer support and resources for urban youth include organizations that work with youth in foster care, provide employment opportunities or present scholarship opportunities.

Families are also contributing partners to student success and transition to adulthood. This can range from full support to minimal engagement, such as providing income information for financial aid applications. Students such as Michael often come from collectivistic families in which parents have a large influence — and in some cases, the ultimate voice — in students’ postsecondary decisions. Families who do not favor students’ goals, or fear the educational process, may take an adversarial stance.

In urban schools, many parents have limited engagement with the school and educational process for a wide range of other reasons, such as a schedule that involves working two or more jobs, caring for family members or many other obligations. In addition, parents who have limited experience or past negative experiences with educational institutions may hesitate to engage with the school. Schoolwide events that aim to connect with families and address their needs can provide education and support in areas such as financial planning to help overcome informational and pragmatic barriers. In addition to holding events, the College and Career Center welcomes parents to meet individually with staff regarding concerns about college. The center also provides bilingual staff for many families with limited English fluency.

Following Michael: The college and career readiness process 

Throughout his time in high school, Michael had both indirect and direct exposure to a College and Career Center in his high school. When he entered ninth grade, he and his cohort were exposed to schoolwide events, classroom presentations and a centrally located drop-in center devoted to cultivating a college-going culture. During the 10th grade, he was introduced to the PSAT and participated in field trips to colleges and universities. In 11th grade, Michael and all of his classmates met individually with a College and Career Center staff member to talk about post-high school plans and what to expect during senior year.

During this intake meeting, the discussion focused on determining what plans, if any, Michael had beyond high school and gauging his understanding of postsecondary education. Program staff evaluated Michael’s transcripts with him to determine college admissions eligibility and to create an educational plan for the remainder of high school. The plan outlined which courses to take, when he should take the SAT/ACT, deadlines for college applications, appropriate financial aid and scholarships, as well as suggested extracurricular activities and other college preparatory activities. Michael learned that he was eligible for admission to a state university if he made up a few failed courses.

Thrilled with the news, he began to plan for summer school to make up his failed courses, studied for the SAT, researched colleges and universities, investigated scholarships and worked toward maintaining good grades. He participated in “college week” workshops that were facilitated by Seven Tepees staff and university and college partners. The workshops focused on topics such as financial aid and scholarships, admissions, career decision-making and other relevant topics.

At the start of his senior year, Michael was eager to start applying for college, and he had established a bond with the College and Career Center staff. With guidance and assistance, he applied to eight universities and also began looking for and applying for scholarships. Michael was on track to enter a four-year university and was excited to become the first member of his family to graduate high school.

Michael returned after winter break of his senior year noticeably uninspired and disconnected from his studies. He came to school less frequently, and his grades began to drop. The school counselor initiated a meeting that included his teachers and personnel from key departments with which Michael worked closely, such as the College and Career Center, the School Counseling Department, the Wellness Center and the After School Program. During the meeting, Michael’s teachers expressed their concerns with his grades. They shared information Michael had provided regarding his familial obligations as the eldest child and his need to care for younger siblings while his parents worked long hours. Moreover, considering his family’s low income, the teachers speculated that Michael might be experiencing anxiety about the cost of college. The school staff developed a shared understanding of the issues and then invited Michael’s family to collaborate.

Parents of urban youth may be unable to participate fully in this type of process because it would mean missing work and losing necessary income. However, when a student is in jeopardy of not graduating or if the student is losing a potential opportunity to enter college, the parents or guardians usually make the sacrifices necessary to participate to the extent they are able. Sensitivity and cultural competence is critical in these types of discussions. Sometimes, they may require the additional involvement of staff members who can provide a cultural perspective and offer linguistically appropriate communication relevant to the student.

In Michael’s case, everyone on the school team worked together to create a culturally congruent proposal to address the many challenges he faced. Michael’s parents attended a meeting to discuss his potential and the current difficulties given the family’s financial burdens and child care challenges. After the counselor and support staff provided information regarding community resources for the family, Michael’s family was able to devise an alternative plan for child care that would allow Michael to spend more time with tutors after school. His teachers and the After School Program were able to offer tutoring services to help Michael raise his grades, while the Wellness Center provided counseling around the anxiety he was feeling. The College and Career Center worked with Michael to reevaluate and adjust his initial educational plan to get him back on track for college acceptance. The center’s staff also helped him search for scholarships and apply for federal and state financial aid, and discussed more affordable college options with him, including local universities that would allow Michael to live at home, thus reducing housing costs. Michael and his family continued to face challenges, but with guidance and assistance from partners, along with engagement from the family, he was able to move forward and was accepted to several local state universities.

With many students, the vigilance and support of the team can help identify and address challenges that might arise in the transition process before they become prohibitive. For other students, challenges will require a revision of the plan. With the help of counselors and a College and Career Center that is invested in each individual student’s story, a new plan can continue to help these youth move forward toward adulthood in a positive way.

Recommendations for counselors

Counselors are important contributors to the multifaceted approach needed to address students’ transition to adulthood. School counselors, college counselors, wellness counselors, mental health counselors, career counselors and rehabilitation counselors all offer important expertise and perspectives in this area.

The importance of multicultural and advocacy competence cannot be overstated, and it is an ethical imperative for counselors to gain and maintain their knowledge, self-awareness and skills toward these competencies. The Multicultural Competencies and the Advocacy Competencies adopted by the American Counseling Association provide valuable guidance. For example, the Advocacy Competencies describe the ways that counselors can advocate on individual, organizational and policy levels and provide recommendations for the types of skills and knowledge that facilitate the role of advocate at these levels. In addition to providing direct service, counselors can play a pivotal role as a touchstone for the observations of teachers and other staff members, organizing information and facilitating collaboration when interventions are needed in the system.

Conclusion

Michael’s situation offers just one example of the barriers that can prevent forward movement toward successful adulthood transition for urban youth. Partnerships between collaborators become a critical component in helping students such as Michael. Yet the functionality of the model and its results will vary because each individual, family, school and community presents different needs and concerns. The central contributor to success is the development and maintenance of partnerships and collaboration. Everyone is an important player with expertise to share and the ability to foster success.

 

****

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

 

Amie Tat is the college success coordinator for the Seven Tepees Youth Program and a second-year graduate student in college counseling in the Department of Counseling at San Francisco State University.

 

Rebecca L. Toporek is an associate professor and coordinator of the career counseling and college counseling specializations in the San Francisco State University Department of Counseling. She served on the task force that developed the ACA Advocacy Competencies. Contact her at rtoporek@sfsu.edu.

 

Letters to the editor: ct@counseling.org

 

The toll of childhood trauma

By Laurie Meyers June 23, 2014

Little-girl_brandingMention the word trauma to Americans in the 21st century, and their thoughts are likely to turn to images of terrorism, war, natural disasters and a seemingly continual stream of school shootings. The horrific scenes at Newtown and Columbine still dominate public consciousness, particularly when our society discusses child trauma. While those events make headlines, however, counseling professionals say the most pervasive traumatic threat to children is found not in big events or stranger danger, but in chronic and systemic violence that happens in or close to the home.

This kind of ongoing trauma, much of which takes place out of public view, leaves deep scars that can cause a lifetime of emotional, mental, physical and social dysfunction if left untreated. Research shows that chronic, complex trauma can even rewire a child’s brain, leading to cognitive and developmental issues.

The good news is that counselors in all areas of practice — in schools, agencies, shelters, clinics, private practice and elsewhere — can and are working with children and, when possible, their parents to stop the cycle of violence, or at least to mitigate its effects.

Behind closed doors

The number of children exposed to violence in the United States is staggering. According to the National Survey of Children’s Exposure to Violence (NatSCEV), funded by the U.S. Department of Justice and the Centers for Disease Control and Prevention (CDC) and carried out by the University of New Hampshire’s Crimes against Children Research Center, more than 60 percent of children surveyed had been exposed to direct or indirect violence during the 12 months prior to the survey. Nearly half — 46.3 percent — had been assaulted at least once in the past year, meaning they had experienced one or more of the following: any physical assault, assault with a weapon, assault with injury, attempted assault, attempted or completed kidnapping, assault by a brother or sister, assault by another child or adolescent, nonsexual genital assault, dating violence, bias attacks or threats. One in 10 had experienced some form of maltreatment, which includes nonsexual physical abuse, psychological or emotional abuse, child neglect and custodial interference. Other CDC research indicates that 1 in 4 girls and 1 in 6 boys are victims of sexual abuse. However, many experts emphasize that due to the stigma involved, sexual abuse is underreported.

Significant exposure to violence and trauma can also lead to illness later in life. From 1995-1997, the CDC, in collaboration with Kaiser Permanente, collected detailed medical information from 17,000 patients at Kaiser’s Health Appraisal Clinic in San Diego. These patients also answered detailed questions about childhood experiences of abuse, neglect and family dysfunction. The initial study, Adverse Childhood Experiences, as well as more than 50 studies since using the same population, found that adult survivors of childhood abuse are more likely to develop chronic conditions and diseases such as heart disease, obesity, cancer, chronic obstructive pulmonary disease and liver disease. They are also more likely to engage in risky health behaviors such as smoking and drug and alcohol abuse. In addition, adult survivors of child abuse may have autobiographical memory problems; exhibit increased problems with depression, anxiety and other mental illnesses; and struggle with suicidal tendencies.

NatSCEV data, collected between January and May 2008, indicate that one in 10 children surveyed experienced five or more incidents of direct violence. It is this kind of ongoing abuse that can cause polyvictimization, or what many researchers call complex trauma — repeated exposure to traumatic events over time and often at the hands of caregivers or other loved ones.

“This cumulative trauma has much more serious effects than a single event,” says David Lawson, a licensed professional counselor (LPC) and licensed marriage and family therapist in Nacogdoches, Texas, who has worked with victims and perpetrators of sexual and domestic abuse since the 1980s. Because the abuse is ongoing, it disrupts a child’s sense of security, safety and self and alters the way he or she sees others, explains Lawson, an American Counseling Association member who is also a researcher and professor in the school psychology and counseling program at Stephen F. Austin State University in Nacogdoches.

“In childhood, attachments are still forming, and abuse can shatter this developing ability,” says Jennifer Baggerly, an ACA member, LPC and play therapist who studies child trauma intervention. “It can also distort their forming personality and the way they interact with people as a whole.” This distortion can cause the child to believe that the world is an unsafe place and that people aren’t trustworthy, adds Baggerly, an associate professor and chair of the Department of Counseling and Human Services at the University of North Texas at Dallas.

That pattern of uncertainty and instability can cause cognitive distortion, dissociation and problems with emotional self-regulation and relationship formation, and even alter a child’s brain structure, notes Lawson, the author of Family Violence: Explanations and Evidence-Based Clinical Practice, published by ACA in 2013.

“Children get stuck in flight or fight,” adds Baggerly. “Everything is a threat, so instead of strengthening the prefrontal cortex, the brain operates more from the limbic system, which causes them to be more hypervigilant.”

Because they are almost constantly on alert, these children and adolescents most of the time use what Lawson calls their “survival brain” instead of their “learning brain.” Childhood and adolescence are periods in which the brain is developing rapidly and crucial cognitive skills are being learned. If children and adolescents spend too much time in survival mode, they are not accessing areas in the brain that are responsible for learning developmentally appropriate cognitive skills and laying down the neural pathways that are critical to future learning.

“As the child gets older, this chronic hypervigilance — and the overload of cortisol that comes with it — completely remaps the brain and just stifles development,” says Gail Roaten, president-elect of the Association for Child and Adolescent Counseling, a division of ACA. “You see them lose ground cognitively, especially in their ability to learn.”

Support and stability

Traumatized children’s problems with cognition, learning, self-regulation and development can last a lifetime, making it more likely that they will continue the cycle of abuse in their relationships, abuse drugs and alcohol, have trouble finding and keeping jobs or end up in the criminal justice system. Adults who were traumatized as children also are much more likely to face a host of physical and mental health problems.

The situation is far from hopeless, however. Counseling interventions for trauma can make a dramatic difference, and the earlier a child starts receiving therapy, the better. A variety of techniques have proved to be effective, but interventions are most successful when a supportive environment is created, Lawson emphasizes. Whenever possible, a parent or parents should be participants in a child’s therapy (as long as they are not the perpetrators of the abuse), and if not the biological parents, then foster parents or grandparents.

“I try to bring in whoever can help build a support system for the child,” Lawson says, “because an hour a week [of counseling] is woefully inadequate, and I need to have them able to take what they learn in therapy into the home.”

In many cases, parents or caregivers need help learning how to support the abused child emotionally, he says. When parents come to sessions with their children, the counselor can help the parents learn not just the best way to support the child in therapy, but also how to strengthen their parenting skills.

“We really emphasize connection,” Lawson says. “Once they [abused children] have attachment, they may be ready to tell parents about their abuse and may just blurt it out at home. I try to prepare parents to listen to the child. If the parents are not comfortable addressing this [topic], I have them at least write down what the child says and then use that as a therapeutic prompt.”

In sessions, Lawson guides parents, teaching them how to interact and better bond with children who have been traumatized. Some parents and caregivers have never really learned how to play with their children, he says.

At the same time, he notes that learning positive interaction skills is not just about the fun stuff. Parents and caregivers also need to know how to effectively discipline the child. “Many times when parents find out that their child has been abused, they are hesitant to discipline or correct behavior because they feel sorry for them,” he says. “Or they come down too hard.”

Lawson encourages parents to use time-outs, to not respond when a child is acting out with attention-getting behavior and to not use corporal punishment.

In the absence of parents or other supportive adults, the counselor may become the stabilizing adult in a traumatized child’s life. Although the counselor is not with the child as often as a parent or caregiver would be, just having someone who is concerned and will listen to whatever the child wants to say can be enough for an abused child to start to heal, Lawson says, even if he or she never chooses to talk about the abuse. He notes that even in the absence of other supportive figures, the therapeutic bond between counselor and child can help in decreasing hyperarousal.

Counselors need to know that although it may seem best to address the child’s trauma right away, establishing and cementing the therapeutic relationship must come first, Lawson says. The child needs to feel safe and supported — even if it is only in the counselor’s office — before he or she can begin to process the trauma.

“You’re trying to get them in a safe place if possible, or at least a predictable place,” Lawson says. “Then we can start teaching them how to cope [with the trauma] without lashing out or
avoiding it.”

Abused children do not know how to cope with what they are experiencing, Lawson says. It is common for children who are traumatized to lash out in anger when stressed and to feel that the best way to establish some sort of stability in their lives is to try to control everything. They may be moody, irritable or withdrawn. Abused children may also bully and hit other children or turn their anger on themselves and engage in self-abusive behaviors such as cutting.

Once a child feels supported, the counselor can also begin to teach the child how to self-soothe. Lawson guides traumatized children in using calming techniques such as diaphragmatic breathing or grounding themselves by focusing on something external such as the ticking of the clock or the texture of their clothes. “The point is to experience emotions in a safe place and cut out bad coping behaviors,” he says.

Safety first

Jennifer Foster, an assistant professor in the Department of Counselor Education and Counseling Psychology at Western Michigan University, studies child sexual abuse. Much of her research has involved listening to the narratives of abuse victims and how they perceive what has happened to them. Although these children display myriad reactions and emotions, Foster says two themes are always prominent: fear and safety.

“Child victims of sexual abuse often view the world as unsafe and are likely to enter counseling with unresolved fears,” Foster says. “They need help from their counselor to learn how to cope with their fears.”

“Although adults often see disclosure as a positive thing that will put an end to the abuse, for many children it is embarrassing and frightening, especially for those who feel at fault for their abuse and believe they will be blamed or, worse, not believed,” says Foster, who studied the experiences of sexually abused children for her dissertation.

Several counseling interventions are designed to help sexually abused children regain a sense of safety. One is called the “safe place technique,” in which a counselor guides the child in visualizing and vividly describing an imaginary safe place.

“The counselor may say, ‘Close your eyes and picture a special place where you feel completely safe,’” Foster explains. “This can be followed by specific questions to capture additional details such as: What do you see? What do you hear? What do you feel? What are you doing in your safe place? The details are recorded by the counselor and used to create a script.”

Once the safe place has been established, the child can return to it mentally anytime he or she feels stressed or scared, Foster says.

Another intervention called the “comfort kit,” developed by Liana Lowenstein, helps children who engage in nonsuicidal self-injury to learn self-soothing strategies, says Foster. “Counselors help children brainstorm and create a list of items that bring them comfort and make them feel better,” she explains. “Although the process is guided by the counselor, children are the ones who choose what will go inside their box or bag.”

Foster says children commonly include items such as a blanket, music, a favorite stuffed animal, written or recorded guided imagery, a stress ball, a list of relaxation activities, bubbles (for deep breathing exercises), a favorite book, a picture of a caring person or special place, a journal and pen, art supplies and a list of self-affirmations.

Foster is also a proponent of bibliotherapy. “Children’s books about sexual abuse can introduce child victims to others who have had similar experiences, which may lead to decreased feelings of isolation and normalize their trauma-related symptoms,” she says.

Books can also provide comfort, offer coping suggestions and teach kids important lessons such as that the abuse is not their fault, Foster adds.

Because fear is a predominant issue for child victims of sexual abuse, Foster also recommends stories that specifically address feeling afraid. Her suggestions include Once Upon a Time: Therapeutic Stories That Teach and Heal by Nancy Davis and A Terrible Thing Happened: A Story for Children Who Have Witnessed Violence or Trauma by Margaret Holmes. To help older adolescents explore their memories and feelings connected to sexual abuse, Foster recommends The Secret: Art & Healing from Sexual Abuse by Francie Lyshak-Stelzer. Foster notes that the author’s artwork is particularly effective at capturing fear and the myriad other feelings generated by abuse.

Finding relief through play

Play therapy is one of the most commonly used interventions with children, particularly those who have suffered complex trauma, meaning they have experienced long-term (and often multiple types of) abuse, says Roaten, an LPC who works with traumatized children in clinics and schools, and an associate professor at Hardin-Simmons University in Abilene, Texas.

Most therapeutic playrooms feature a fairly specific set of toys that might include an art center, play dough, a Bobo doll (an inflatable plastic doll modeled after the inflatable clown used in Alfred Bandura’s seminal study on children and aggression), a dollhouse with miniature people, animal figures, toy weapons, costumes and a sandbox. These toys and activities help children to act out their experiences in a safe and less negative manner, Roaten says. For instance, she recounts treating one child who “would just attack and slash the doll where the penis was. She was a victim of sexual abuse.”

In some cases, Roaten says, children just “play through,” processing their trauma entirely through play without needing to talk to the play therapist.

In many instances, Baggerly says, traumatized children act out things they aren’t able to verbalize. She once treated a 6-year-old who didn’t speak for about 10 sessions because the girl had a severe case of internalized anxiety and depression. But as the girl played, she would express her rage by taking a gun and shooting the Bobo doll in the head, stomach and groin area. Baggerly took this cue as a chance to ask the child about the anger and hurt she was feeling.

Catherine Tucker, a licensed mental health counselor who works with traumatized children in her role as a counselor supervisor and consultant, uses a child and family therapy called Theraplay, which was developed by the Theraplay Institute in the 1960s. “Theraplay works on a four-dimensional model: structure, nurture, engagement and challenge,” says Tucker, an associate professor in the college of education at Indiana State University.

Theraplay builds and enhances attachment, self-esteem, trust in others and engagement through participation in simple games. The idea is that the four dimensions — structure, nurture, engagement and challenge — are needed by children for healthy emotional and psychological development. The “play” in Theraplay is built around activities that teach participants what the elements of those dimensions are. Ideally, children engage in Theraplay with their parents or caregivers. Participating together teaches skills to parents or caregivers who don’t know how to provide the four dimensions, while enhancing the bond with the child. In the absence of parents or caregivers — whether because they are abusive or because they cannot or do not want to participate — the counselor plays directly with the child so the child can still learn how to interact in an emotionally healthy way.

The games and activities are simple — suitable for children as young as 1, yet still engaging for older children — and include things such as blowing bubbles, playing with stuffed animals, cotton ball hockey, cotton ball wars and newspaper basketball. The activities teach parenting skills and also help traumatized children with affect regulation, impulse control, feeling safe and not feeling like they have to be in control of the world, Tucker says. She notes that, oftentimes, kids who have suffered trauma feel like they have to be in charge either because a parent is abusive or simply doesn’t know how to provide a sense of security or stability, or because the child’s sense of control is being undermined by the abuse he or she experienced at the hands of another adult or peer.

Finding help at school

Counselors who are treating traumatized children should tap all available resources to help these clients, Lawson says, working not only with caregivers or other relatives but also with the child’s school. School counselors may be a source of additional one-on-one counseling for the child, or they could get the child involved in group activities with other children who are trauma victims or with children who share common interests such as music, sports or art, Lawson says. These peer networks provide abused children additional sources of support and can also teach them how to interact with people — something that many abused and isolated children have never learned to do.

Perpetrators of abuse seek to control and isolate their victims. An abusive parent has the power to cut off or severely limit a child’s healthy interactions with people outside of the circle of abuse. “[These] kids often didn’t learn social skills because they are kept away from other people,” Lawson says.

Abuse is often part of a viciously long-lived cycle, handed down from generation to generation, Lawson adds. Parents who were abused as children often grow up to abuse their own children. Even if parents with an abusive background are not abusive themselves, they may still carry on other dysfunctional behaviors, he says.

“You may have three or four generations of people [who] have a very skewed view of how to interact with people,” he says. “So they never learn how to interact with others. You have to help [these children] connect with other sources.”

School counselors also can play important roles as advocates and educators. Many people — including teachers and administrators — do not understand that many children who act out are doing so because they have been or are being abused, Tucker asserts.

“School counselors can really make a difference by making sure that kids get evaluated instead of just automatically disciplined,” Tucker says.

“So many boys end up in the criminal justice system because they were physically acting out in response to trauma,” she adds.

School counselors can also help abused and traumatized children learn how to help themselves, says Elsa Leggett, an ACA member, associate professor of counseling at the University of Houston-Victoria and president of the Association for Child and Adolescent Counseling.

“Talk to kids about safety plans,” Leggett urges. “Ask them, ‘When abusive things are going on at home, where do you go? How do you know when things are getting dangerous?’”

The most important thing that all practicing counselors can do to address childhood trauma is to ask questions, Lawson says. Children — and sometimes adults who were traumatized as children — don’t always recognize what they’ve experienced as abuse, so rather than asking “have you been abused?” Lawson instructs his students to pose questions such as “has anyone ever hit you?” and “has anyone ever touched you in a way that made you feel uncomfortable?”

ACA member Cynthia Miller is an assistant professor of counseling at South University in Richmond, Virginia, and an LPC who has worked with incarcerated women. She has seen the kind of positive change that can occur when people get the help they need, but she has also witnessed the pattern of incarceration, addiction and institutionalization that can become entrenched in generation after generation.

“If you want to decrease the amount of money we spend on treating people with substance abuse or incarceration,” Miller says, “address child abuse.”

Caring for children during a disaster

Although ongoing trauma causes the biggest and longest-lasting kind of damage, one-time events can also create problems that linger. It is particularly important for children to receive timely counseling intervention, experts say.

“Typically, most children will have short-term responses to a disaster that include five basic realms,” Baggerly says. These realms are:

  • Physical: Symptoms include headache or stomachache
  • Thought process: Children exhibit confusion and inattention
  • Emotional: Children are scared and sad
  • Behavioral: Children might become very withdrawn or clingy, or may start sucking their thumb or wetting the bed again
  • Spiritual/worldview: Children may question their beliefs about God and the world

(For more information about typical trauma responses and recommended interventions, see “Children’s trauma responses and intervention guidelines” below.)

“Typically these [responses] don’t last long,” Baggerly says, “but that depends on the kind of support kids get in the immediate aftermath.”

Ultimately, the purpose of any counseling intervention after a traumatic event is to reduce or eliminate a child’s anxiety and stress, Baggerly asserts. She attempts to do that by “resetting” the child and connecting him or her to coping strategies.

“They need caring family and community support,” Baggerly says, “but if it is a huge disaster, then parents and teachers are equally traumatized, so they are not able to give support to kids. That’s when you need to bring people from outside.”

Some children are at greater risk than others, Baggerly says. “Kids who don’t have supportive family [and] who already have anxiety or have some type of developmental disability often will have ongoing symptoms that go longer than 30 days,” she explains. “Counselors need to triage to find out who is at most risk.”

During her roughly dozen years of experience working with chronic trauma and disasters, Baggerly has developed an integrated approach that she calls disaster response play therapy. The approach uses a trauma-informed philosophy in which counselors train parents and teachers in typical and atypical reactions to disasters so they can screen children and determine which ones need more help, she explains. “We also normalize typical symptoms, provide psychoeducation that informs kids about the impact of disasters, teach them coping strategies and provide them with child-centered play therapy.”

Baggerly usually begins by gathering a group of children and talking with them about rebuilding the community. She also encourages children to use expressive arts or drama to communicate their feelings.

“The other part of what we do is facilitate connection and conversation between kids and parents,” Baggerly says. “We may start out with Theraplay and do structured activities, such as holding hands or singing ‘Row, Row, Row Your Boat.’ The point is to have them [parents and children] looking at each other so that the mirror neurons can be engaged.”

Baggerly also educates parents on activities they can do at home with their children. She refers them to an online workbook, “After the Storm,” which has scales of 1 to 10 or a thermometer that kids can fill in to indicate how much stress they are feeling.

Roaten often does volunteer trauma work and provided on-site support in the wake of the April 2013 fertilizer plant explosion in West, Texas, that killed 15 people, injured more than 150 and caused extensive damage to buildings and property.

“One girl, a seventh-grader, had been standing outside in a neighborhood with a view of the plant and observed the explosion itself,” Roaten says. “So she had that image in her head and it would not go away. I taught her some deep breathing and progressive relaxation and did some guided imagery about her favorite place to be.

“When that picture came up in her mind, she could breathe, relax and go to her good place. By the fourth day I was there, she was no longer seeing the image.”

Roaten uses expressive therapy for children who aren’t very verbal or who don’t have the vocabulary to talk about their feelings. She brings a sand tray with miniatures of fences, people and buildings. She then allows children (and even adults) to set up scenarios or vignettes that help them express and act out what they are feeling.

“I might say something like, ‘Create your world before [Hurricane] Katrina; then create your world after Katrina,” Roaten explains.

Roaten also uses trauma-focused cognitive behavior therapy to help children and adolescents learn coping skills.

“You teach them about trauma and its impact on them,” she explains. “Then you teach them relaxation and breathing skills. Once you get them to be able to self-soothe, relax and be calm, you can help them deal with pictures or scenarios that come up. You help them change the story — what they are telling themselves and what that means — which helps them work through the trauma a little bit at a time.”

****

Children’s trauma responses and intervention guidelines

 

Preschool through 2nd grade

Typical trauma responses:

  • Believes death is reversible
  • Magical thinking
  • Intense but brief grief responses
  • Worries others will die
  • Separation anxiety
  • Avoidance
  • Regressive symptoms
  • Fear of the dark
  • Reenactment through traumatic play

Intervention guidelines:

  • Give simple, concrete explanations as needed
  • Provide physical closeness
  • Allow expression through play
  • Read storybooks such as A Terrible Thing Happened, Brave Bart, Don’t Pop Your Cork on Monday

 

3rd through 6th grade

Typical trauma responses:

  • Asks a lot of questions
  • Begins to understand that death is permanent
  • Worries about own death
  • Increased fighting and aggression
  • Hyperactivity and inattentiveness
  • Withdrawal from friends
  • Reenactment though traumatic play

Intervention guidelines:

  • Give clear, accurate explanations
  • Allow expression through art, play or journaling
  • Read storybooks

 

Middle school

Typical trauma responses:

  • Physical symptoms such as headaches and stomachaches
  • Wide range of emotions
  • More verbal but still needs physical outlet
  • Arguments and fighting
  • Moodiness

Intervention guidelines:

  • Be accepting of moodiness
  • Be supportive and discuss when they are ready
  • Groups with structured activities or games

 

High school

Typical trauma responses:

  • Understands death is irreversible but believe it won’t happen to them
  • Depression
  • Risk-taking behaviors
  • Lack of concentration
  • Decline in responsible behavior
  • Apathy
  • Rebellion at home or school

Intervention guidelines:

  • Listen
  • Encourage expression of feelings
  • Groups with guiding questions and projects

 

Source: “Systematic Trauma Interventions for Children: A 10-Step Protocol,” by Jennifer Baggerly in Terrorism, Trauma and Tragedies: A Counselor’s Guide to Preparing and Responding, third edition, American Counseling Association Foundation, 201

 

****

ACA Traumatology Interest Network

Counselors and counselors-in-training who have an interest in providing counseling services to trauma- or disaster-affected individuals and communities should consider joining the ACA Traumatology Interest Network. Network participants share insights, experiences, new plans and advances in trauma counseling services. For more information on joining the interest network, go to counseling.org/aca-community/aca-groups/interest-networks.

 

****

To contact individuals interviewed for this article, email:

****

Laurie Meyers is the senior writer for Counseling Today. Contact her at lmeyers@counseling.org.

Letters to the editor: ct@counseling.org

OMG: Texting while driving surges among teens even as other risky behaviors continue long-term declines

By Bethany Bray June 20, 2014

U.S. teenagers are smoking cigarettes less frequently but texting while driving more.

The Centers for Disease Control and Prevention (CDC) released the most recent data from its biennial Youth Risk Behavior Survey this week, which showed smoking among teens continues a long-term drop. Cigarette smoking among U.S. high school students is the lowest it has been in 22 years, according to survey data. Sexual activity and alcohol use by teens have also been on a long-term decline since the 1990s.

youth-risk-graphicHowever, close to half of those surveyed admitted to texting or sending an email while driving sometime in the past month.

More than 13,500 U.S. students took the most recent Youth Risk Behavior Survey.

The survey, administered by the CDC every two years, asks young people a wide variety of questions related to health and risk behaviors, from whether they wear a seatbelt while in a car and whether they typically eat breakfast to if they’ve had sex, use birth control or used marijuana, cocaine or other drugs. The questionnaire is voluntary and anonymous.

The survey also includes questions about mental health, including whether a student has thought about attempting suicide or “felt sad or hopeless” consistently.

 

Key findings include:

  • Cigarette smoking rates among high school students have dropped to 15.7 percent.
  • The percentage of high school students nationwide who had been in a physical fight at least once during the past 12 months decreased from 42 percent in 1991 to 25 percent in 2013.
  • Fights on school property have been cut in half during the past 20 years, from 16 percent in 1993 to 8 percent in 2013.
  • Nationwide, 41 percent of students who had driven a car or other vehicle during the past 30 days reported texting or emailing while driving.
  • The percentage of high school students who are sexually active declined from 38 percent in 1991 to 34 percent in 2013.
  • Among sexually active high school students, condom use declined from 63 percent in 2003 to 59 percent in 2013.

 

The survey was taken by students in ninth through 12th grades across the United States, in both public and private schools, between September and December 2012.

The full results are posted at CDC.gov. The data is searchable by state and region; information from past surveys and nationwide trends are also available.

 

 youth-risk-graphic-2

 

 

 

****

 

 

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

 

There’s no such thing as bully-proof

By Bethany Bray April 28, 2014

“Instead of thinking about bullying, we should think about belonging,” says Stan Davis, a researcher on peer mistreatment and school dynamics.

The most effective way to combat school bullying is to work toward having students accepted by their peers, asserts Davis, a retired school counselor and child and family therapist in Maine.

bullyingThe majority of anti-bullying curriculum used in schools encourages bystanders and peers to speak up or intervene when they see bullying. According to Davis, not only is this tactic ineffective, it can actually make the bullying worse.

Davis and his co-researcher, Charisse L. Nixon, associate professor of developmental psychology at Penn State Erie, recently surveyed 13,000 public and private school students in 31 schools across the United States about bullying and school culture. They published their results and analysis in the 2013 book Youth Voice Project: Student Insights Into Bullying and Peer Mistreatment.

Of the 13,000 youths surveyed, 3,000 said they had been mistreated by peers repeatedly, two times a month or more.

High schoolers who took the survey named two tactics as most effective in disarming a bully: walking away from the situation and pretending that it didn’t bother them. At the same time, they said the assertiveness and intervention methods commonly taught in anti-bullying programs often led to negative outcomes.

“What [students said] worked better than anything was when kids were included by their peers,” Davis says. “It was twice as effective as asking the bully to stop.”

Davis believes school staff and therapists should focus on the school culture as a whole rather than trying to make kids “bully-proof.” While he isn’t suggesting that schools shouldn’t try to reduce instances of bullying, he says the reality is that there is no way to stop all mean behavior among school students. Instead, healing, belonging and connecting should be the focus of anti-bullying efforts, he says.

Davis illustrates his point with an analogy of safety airbags in vehicles: We are not going to stop car crashes altogether, but we can make them “survivable,” he says.

“[It’s] a seductive idea – that a therapist will make a child so confident that the bullying will stop,” Davis says. “We need to switch and realize, ‘I don’t have any magic that will make the bullying stop.’ There is no such magic. … We can’t give the kid some kind of mystical shield.”

Therapists should use a cognitive approach with students who have been mistreated by peers, says Davis. Assure them the bullying is not their fault but simply a choice that another person made.

“The idea that a kid could change the behavior of another kid is fantasy,” he says. “It just doesn’t happen.”

Instead, focus on enhancing the mistreated student’s social network and sense of belonging, Davis suggests.

As is the case with victims of domestic violence, targets of bullying should never be made to feel they brought the situation upon themselves, Davis says. Avoid anything that implies the student should make personal changes – be less flamboyant, behave differently, opt for a less noticeable hairstyle, etc. – to stop inviting bullying.

It’s a misconception that victims are made targets of bullying because they’re not assertive, Davis says.

According to their survey results, Davis said assertiveness worked just 20 percent of the time in bullying situations. In a majority of situations, it just made things worse, he says.

Fifty-six percent of youths said the situation got better when a peer spent time with them at school. Private expressions of support between students, such as sending a text message, were also helpful, he says.

 

WORKING WITH THE BULLIED

Here are some ways Davis suggests counselors can help students who have been mistreated by their peers:

  • Focus on helping the bullied student see who was at fault: the other person. Bullied students are not responsible and could not have stopped another person’s behavior.
  • Help the student filter what the other person says: It’s not real, and it’s not important.
  • Help the student enhance his or her social interaction (finding friends through joining clubs, doing extracurricular activities, etc.). Being passionately involved in a hobby can foster connections that can buffer mistreatment — such as between a coach and player or a player and his or her teammates.
  • Push schools to protect students from bullying as much as possible, but also help kids find a way to belong. For example, start a gay/straight alliance group to foster belonging among straight and lesbian, gay, bisexual and transgender students alike.
  • Students who have been mistreated by peers can benefit from doing community service. Instead of focusing on why they’re being bullied, the students can see how they’re making a difference through volunteer work.

 

****

 

Davis is continuing his research on peer mistreatment and school dynamics, and also leads programs and workshops at schools for staff and students. For details, see his website, stopbullyingnow.com.

 

For details on the Youth Voice Project research and book, see youthvoiceproject.com.

 

****

 

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

****

Counselors and the clinical staging model

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

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

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

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

McGorry Clinical Staging Table

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

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

 

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

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

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

A practical framework 

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

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

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

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

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

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

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

The clinical staging model in a high school 

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

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

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

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

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

****

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

****

 

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

 

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

 

Letters to the editor: ct@counseling.org