Tag Archives: Children & Adolescents

Children & Adolescents

Tools for navigating the world at large

By Laurie Meyers November 22, 2017

By the time children with autism spectrum disorder (ASD) are approaching elementary school age, they are already exhibiting symptoms that typically lead to lifelong social difficulties. Among these symptoms: impaired communication and interaction, an inability to self-regulate and modulate emotions, very narrow and specific interests, and sensory processing difficulties that make it difficult for them to connect with the world at large.

Many counselor practitioners may question whether they are even qualified to work with clients who have ASD. According to the individuals interviewed for this article, however, professional counselors possess a range of skills that can be particularly helpful to this client population.

Stephanie Smigiel, a licensed professional counselor (LPC) who does mobile counseling with ASD clients in the Pittsburgh area as part of the state of Pennsylvania’s behavioral health services, says clients with autism aren’t that different from other populations with which counselors work. She acknowledges that these clients often require a little extra accommodation and counselor ingenuity, but this call to be creative is one of the reasons that she particularly enjoys working with the population.

It is essential, however, that counselors understand clients with ASD and their needs, cautions Smigiel, a member of the American Counseling Association. “Ask yourself, ‘Do I have a bias? Is this a population I can see myself working with?” She notes that people with ASD can have problems controlling their aggression and says it is not uncommon for these clients, sometimes including adults, to pull her hair or scratch her arms.

Neurology tells us that the brains of those with ASD work differently. Those on the spectrum are often labeled as atypical (as opposed to neurotypical). However, those with ASD and many of the people who work with them have begun advocating for a different view: neurodiversity — or the idea that there is no single, correct neurology.

“The neurodiversity movement in the field seeks to apply a culturally competent view of people diagnosed with ASD or other neurological or neurodevelopmental diagnoses,” explains Ali Cunningham, a licensed mental health counselor (LMHC) who specializes in ASD. “As with most cultural groups who are trying to acculturate to the majority group, it is about achieving a balance of honoring individuality and uniqueness while striving to be successful in the majority.”

Cunningham says that many clients with autism struggle with wanting to maintain what makes them unique while still being able to connect with others and navigate the worlds of friendship, romance and work. Culturally sensitive treatment of clients with ASD involves helping them identify how their individuality or uniqueness is a resource while also exploring what new skills or techniques they are willing to integrate into their lives to strike that balance, she says.

“I always try to communicate the message that treatment is not intended to change who you are,” Cunningham says. “Treatment can help highlight the strengths you already have and add to them with skills or techniques that will enhance how you navigate the world and help you meet your goals.”

Boy (and girl) meets world

Because ASD presents early in life, experts in the field emphasize the importance of early intervention. One of the primary ways that professional counselors can help clients with ASD manage the challenges that come with the disorder is by targeting and teaching social skills.

Tami Sullivan, an LMHC and registered play therapist, maintains a private practice in Brockport, New York, that includes ASD as one of its specialties. She uses play therapy to connect with child clients who have autism.

“Children often make sense of their world and the people in it through play,” says Sullivan, a member of ACA. “Play can be used as an intervention [because] it is the native language of childhood. Counselors can understand children, the child’s world and his or her perspectives in the context of play therapy.”

Sullivan notes that children with autism play differently than do their peers without autism. “Children with autism have a low level of engagement in play. Their play is more concrete, private, ritualized … and restrictive,” she says.

She explains that young children with ASD possess limited imaginary or “pretend” play skills. Their tendency to engage exclusively in solo play and difficulty participating in imaginary worlds isolates these children and often precludes them from developing meaningful relationships or friendships with other children.

Sullivan uses a nondirective play therapy approach to engage children who have ASD. This means that rather than using a prescribed set of games or toys, she lets the child take the lead, exploring at his or her own pace.

“In this nondirective approach, the relationship is the key therapeutic medium [that] communicates acceptance of the child,” says Sullivan, an assistant professor in the Counseling and Psychological Services Department at the State University of New York at Oswego. “I aim to make the critical emotional connections that support a reciprocal relationship between us. I … encourage [the child’s] initiative and play with the goal of deepening engagement, lengthening mutual attention and regulating emotion and behavior.”

Once these children feel fully accepted, they begin to communicate and engage in reciprocal social interactions, Sullivan says.

When Sullivan wants to target a specific therapeutic goal, she uses more directive play, choosing activities that help build particular strengths in children with autism. For example, by creating something with the child, Sullivan strengthens the child’s ability to take turns, joint attention (the ability to focus on more than one thing at a time) and social perspective.

Sensory exploration can further increase the connection between Sullivan and the child. Many children with ASD use sensory toys to self-regulate, so in addition to baskets of sensory toys, Sullivan has sand trays, big bean bags and pillows, donut balls, a tunnel and a small ball pit in her office. “I am often invited by them to join in as they self-regulate,” Sullivan says. “This can be a time to connect deeper with the child and build our relationship.”

Sullivan collaborates with her clients’ parents or caregivers using two therapeutic approaches: skills-based/solution-focused therapy and filial therapy.

The first approach involves identifying goals and solutions for the child’s behavior and challenges that are causing stress on the family system. Sullivan then works with the parents to identify ways in which they can support and encourage the child as he or she develops new skills and abilities.

For example, children with autism often express anxiety through their behavior. Sullivan teaches parents how to identify this and how to help children recognize what they are feeling. The parents can then prompt their children to use coping skills they have learned with Sullivan, such as relaxing their bodies, distracting themselves or trying to change the way they feel about a situation.

With filial therapy, Sullivan says the work centers around strengthening the parent-child relationship in the counseling process. This is done in part by teaching parents play therapy relationship-building techniques such as reflecting the child’s feelings, empathic listening, imaginary play skills and limit setting.

Finding friends

During the elementary, middle school and high school years, social skills become even more critical, Sullivan says, particularly as they relate to the making and keeping of friends. “These children [her clients with ASD] desperately want to have friends, but they don’t know how,” she says.

Sullivan uses group therapy to help children with autism cultivate stronger social and relationship skills. She holds one group for children of elementary school age and another for clients of middle and young high school age.

When designing the groups, Sullivan decided the training for the elementary school-age children would be more effective if it featured an element of play. She chose to incorporate Lego-based therapy, a method pioneered by neuropsychologist Daniel LeGoff after he noticed that when children with ASD worked together to build things, they were more naturally inclined to socialize with each other. Sullivan pairs the Lego therapy with a structured lesson. She says the underlying play therapy lessens the children’s anxiety about the group while the building exercises aid in teaching social and friendship skills.

The group meets for 90 minutes once a week for 10 weeks. It is run by a professional counselor (either Sullivan or her colleague) and a relational coach who demonstrates social skills by engaging in role-play with the counselor.

Each session starts with a sensory warmup in which group members can play with sensory toys. After the warmup, the leaders and participants decide, as a group, what kind of Lego structure they want to build that day. The building process is collaborative and uses defined roles such as builder, supplier and engineer. From session to session, the children take turns playing each role. Once roles are assigned, the group must work together to decide how to go about building the structure.

As the group is building, the leaders introduce that session’s topic, such as learning how to have a conversation. The counselor talks about what the skill involves — in this case, trading information — and demonstrates it through role-play with the relational coach. This often consists of “good” role-play and “bad” role-play. For example, you don’t start a conversation by going up and introducing yourself, but you do hang back and wait until a topic comes up that interests you and then join the conversation.

Sessions end in free play, during which the children, over time, begin to interact with each other on their own, Sullivan says. The children’s parents or other family members receive a sheet after each session that outlines the skills the group worked on that week. As homework, parents are encouraged to help their children practice the skills they learned in group.

If possible, Sullivan also provides packets for the children’s teachers. She says that in some cases, teachers call her to collaborate, whereas in others, the parents work with the teachers. Many of the children in Sullivan’s groups are in mainstream classrooms. So, she recommends that their teachers identify peers to serve as social mentors and then provide time for the students with ASD to practice their skills at school.

The group also explores appropriate humor, a topic for which bad role-play is particularly suited, Sullivan says. The relational coach will display inappropriate humor — for instance, using potty language or imitating one kid making fun of another kid — and the counselor will react. Afterward, the coach and counselor ask the group members what they saw: “Did you notice that Tami didn’t laugh and that she actually looked kind of sad?” Then the coach demonstrates appropriate humor by telling a joke, and in response, Sullivan or her colleague will laugh. Sullivan also gives the children (and their parents) a list of appropriate topics to joke about and recommends joke books.

The group also discusses how to be a good sport. “We talk about a lot of things that you don’t do when you want to play a game with someone,” Sullivan says. For instance, “You don’t want to be a policeman or a referee — you don’t want to remind everyone what the rules are all the time.” The lesson teaches children to focus on what their role is in the game and how to participate in a sharing way. The topic also offers an excellent opportunity to talk with group members about additional skills such as dealing with frustration by walking away, taking a break or engaging in deep breathing, she says.

In later weeks, the group experience involves more discussion, such as talking about how to choose an appropriate friend. The children compile lists of qualities that are appealing to them in a friend and what makes a person a bad friend, Sullivan says. She also works with parents to help them brainstorm places, such as school clubs, where children can make positive connections.

Sullivan says the group leaders routinely look for opportunities to point out when children are demonstrating some of the skills they have learned in the group. Recently, during freestyle play, one boy, inspired by the monster structures they had been building, talked about wanting to have a Halloween party. His fellow group members then asked one another about their Halloween costumes and activities.

Teenage training

Sullivan’s group for clients of middle school and younger high school age runs for 14 weeks. It also focuses on conversational skills but covers additional topics such as how to handle rejection, how to handle rumors and gossip and how to be a good host. This group doesn’t incorporate Lego therapy. Instead of starting sessions with sensory play like the younger group, participants in the older group talk about their experiences trying to implement the skills they are learning. They also receive more homework to reinforce those skills.

Sullivan says the group spends a significant amount of time talking about bullying, rumors and gossip. “We teach a lot about how to reinvent yourself,” she says.

For instance, the group leaders emphasize that it is counterproductive to handle rumors or gossip by addressing them directly or denying them because those actions merely create more rumors and gossip, Sullivan says. Instead, they teach participants to redirect by using a sense of humor, walk away if someone is getting in their face and establish support figures in school and at home. They also talk about what to do about a damaged reputation, how to not take rumors and gossip personally, how to find other groups to hang out with and how to identify and connect with supporters within the school.

Sullivan says participants practice skills together during the group sessions, but group leaders also encourage them to set up short get-togethers with friends outside of group. In doing so, the leaders emphasize the need for the group members to practice sharing and exchanging ideas with others during these get-togethers. What group leaders don’t want is for group participants simply to get together for parallel play, such as two people playing video games separately, side by side, Sullivan says.

Group leaders review the process of getting together in great depth, even covering actions as simple as answering the door. “You don’t just open it,” Sullivan tells group members. “Invite the friend in and ask what they want to do.”

Next, the host should present the friend with two possible activities to choose from and let the friend decide which sounds more fun. Once they complete that activity, the host should talk with the friend about what else they could do, Sullivan coaches.

The sessions for Sullivan’s group incorporate ideas from the Program for the Education and Enrichment of Relational Skills (PEERS) for Adolescents model, an evidence-based social skills intervention developed by UCLA’s Semel Institute for Neuroscience and Human Behavior. PEERS focuses on the following topics:

  • How to use appropriate conversational skills
  • How to choose appropriate friends
  • How to appropriately use electronic forms of communication 
  • How to appropriately use humor and assess humor feedback
  • How to start, enter and exit conversations between peers
  • How to organize successful get-togethers with friends
  • How to be a good sport when playing games or sports with friends
  • How to handle arguments and disagreements with friends and in relationships
  • How to handle rejection, teasing, bullying, rumors/gossip and cyberbullying
  • How to change a bad reputation

Conversation starters

Cunningham, who practices at the Children’s Center for Psychiatry, Psychology and Related Services in Delray Beach, Florida, also uses the PEERS for Adolescents program with middle school- and high school-age youth. The groups last 16 weeks, and participants must be accompanied by a parent or someone else who functions as a social coach, she says. The “coach” requirement is in place so that the youth will have support not only for practicing their skills but also for finding opportunities for social engagement, Cunningham says. The clients with ASD meet in one group, while the parents/social coaches meet in a separate group to learn about the skills the youth are acquiring.

Cunningham, an assistant professor of counseling at Lynn University in Boca Raton, says that sessions start with role-play. Facilitators model some common errors related to that week’s skill lessons so that group members can learn what not to do. The facilitators then use role-play to demonstrate scenarios for using the skills effectively. The group participants then rehearse the skills and are given homework requiring them to go out and practice their skills in the outside world.

The group spends a substantial amount of time on conversational skills, beginning with how to start one, Cunningham says. Most people might say that the way to start a conversation is by introducing yourself, but few people actually do that, she notes, because it makes it seem like you’re selling something. Instead, group members learn how to find something that they have in common with the person and then make a comment or ask a question to continue the conversation, she explains.

People with ASD often have very particular, idiosyncratic interests, Cunningham says, so group participants learn about things that most people like to talk about, such as books, TV shows, movies, music or video games. She also tries to help clients understand steps they can take to expand their own interests or to make connections between their interests and the interests of others. For example, one of Cunningham’s clients with autism listens to a niche kind of electronic music. She has explained to him that he might not be able to find other people who listen to that exact music, but he can seek out people who like music that is similar.

After learning to start a conversation, the group moves on to how to maintain one, focusing on elements such as listening and having an equal exchange of information rather than doing all the talking or asking question after question. Participants also learn how to use humor in a conversation, how to pay attention to feedback and how to join a group conversation, Cunningham says.

Bullying is another important topic, but the focus isn’t so much on how to cope with it as how to prevent it from happening in the future, Cunningham says. One thing that group members learn is how to distinguish between actual bullying and straightforward feedback that they may get from someone who is annoyed by their behavior.

Cunningham also runs a PEERS group for adults with autism that includes four weeks focused on dating. (Cunningham doesn’t include the topic of dating in her younger groups but not because she thinks participants aren’t interested. Rather, it’s because parents of children with ASD often aren’t comfortable with their kids exploring romantic relationships, particularly when they still aren’t savvy about friendships.) The dating portion of the program focuses on topics such as appropriate ways to engage in flirting and assessing whether another person is interested.

It isn’t uncommon for men with ASD to be perceived as creepy, Cunningham notes, because they don’t typically understand how to read other people’s cues and might continue pursuing someone who is not interested in them romantically. Meanwhile, there are others with ASD who, despite their desire for a romantic relationship, won’t engage with anyone because they can’t tell if the other person is interested, she says.

Other topics the group discusses include how to handle peer pressure and sexual pressure.

Job hunting

Many people with ASD have trouble finding and keeping a job due to several factors, including a lack of social skills, difficulty understanding workplace culture and sensory difficulties that can cause them to become overwhelmed more easily. However, Smigiel believes that the most significant factor keeping those with ASD from career success is a lack of support.

In essence, Smigiel says, career counseling for those with ASD is similar in spirit to providing career counseling to any other client — it is a matter of finding out the client’s strengths and weaknesses. Smigiel did her internship at a vocational services agency that provided job counseling for those with ASD and intellectual disabilities. The agency helped clients practice their interviewing skills and assigned them a job coach who would try to connect them with positions that matched their skill levels.

Smigiel has worked with people on the high end of the autism spectrum who have found their niche in computer work, but at the vocational agency, they tried to match all clients, including those on the lower end of the autism spectrum, with jobs. “I’m a firm believer that anyone can have meaningful activity,” she says.

The key is to play on the focused nature of those with ASD. “What are they obsessed with?” Smigiel asks. “What can I do with that?”

For instance, Smigiel says the agency had many clients with ASD who loved to clean, so the vocational center helped them set up a car detailing program. The clients’ attention to detail produced “the cleanest cars you ever saw,” Smigiel says.

Counselors working with people with ASD have to think creatively and find that person’s niche, says Smigiel, who believes that everyone on the spectrum possesses strengths. For instance, some clients might be obsessed with organizing, which might make them a good fit for working in a clothing store and keeping all the displays in order.

Clients with ASD also often need help retaining their jobs because they don’t necessarily understand the social skills involved in working with others. As a result, they might ask too many questions, not understand what is and isn’t appropriate to say to a boss or have trouble interacting with co-workers, Smigiel says. In more severe cases, people with ASD might have poor personal hygiene, neglecting to brush their teeth or take a shower either because they don’t see it as a need or because it creates a disturbing sensory sensation for them.

At the vocational center, staff members would provide lessons on the importance of brushing teeth and taking showers, Smigiel says. When teaching these kinds of lessons, counselors should be aware that people with ASD are forthright and won’t want to do something “just because,” Smigiel says. Instead, the staff would say, “You need to take a shower because, otherwise, you’ll smell,” and, “You need to brush your teeth because, otherwise, you’ll get cavities.”

Emotional regulation

Clients with ASD also need help acquiring the self-regulation skills to cope with stress and frustration on the job, says Jamie Kulzer. An LPC in the Pittsburgh area, Kulzer helps clients with ASD and other cognitive disabilities as part of a multiweek vocational training program that teaches cognitive, self-management and vocational skills. The program includes internships with local businesses.

“We have found that emotional regulation is really important because if you’re escalated, [you] can’t access the other resources that you have to deal with problems.”

The program has participants envision an emotional thermometer, with green representing a calm, rational state and red representing a state of extreme sadness, anger or excitement. When individuals are in the red, they are unable to make good decisions, so Kulzer teaches clients to monitor their thoughts and behaviors and to be vigilant to when they are in the “yellow.” She also teaches clients to practice techniques such as deep breathing, visualization or standing up and stretching to help themselves avoid going from yellow to red.

Once clients have returned to a green state, they can approach a problem by asking for help or by using a divide-and-conquer strategy that breaks problems down into smaller, more manageable pieces. They can also express their problem by using “I” statements, such as “I need” or “I don’t understand,” explains Kulzer, an ACA member and assistant professor in the clinical rehabilitation and mental health counseling program at the University of Pittsburgh.

Program participants also learn about the physical and emotional gas tank, which is a measure of mental and emotional fatigue, Kulzer says. A full tank enables the client to be fully alert, present and ready to take in new information. An empty tank makes the client susceptible to aimless daydreaming, flooding emotions, racing thoughts and frustration.

Clients are taught that they can help keep their gas tanks full through self-care measures such as healthy eating, drinking water regularly and getting enough sleep. Kulzer also teaches program participants to approach their work or other projects by breaking them down and doing the easiest parts first and making sure to take frequent breaks.

It is critical for clients with ASD to monitor their physical and emotional gas tanks and to take action when they feel themselves getting to half full, Kulzer says. This means stopping and asking themselves, what’s draining the tank? For one person, it might be staying up too late to play video games, which requires better self-management. For another, it might be the result of being in an overly stimulating environment and needing to take a break by briefly leaving the area, Kulzer says.

In anticipation of the second half of the program, participants work on their vocational skills, which includes an emphasis on general communication. For instance, clients are taught to use “I” statements to talk about their feelings and encouraged to repeat back any request made to them to ensure that they are hearing it correctly and are aware of the nonverbal messages they are sending, Kulzer says.

People with ASD often have difficulty looking others in the eye, which can mistakenly give others the impression of disinterest. Kulzer’s program teaches these clients to say things like, “Eye contact is difficult for me, but I am listening.” Clients are also encouraged to indicate their attention and willingness to work by sitting up straight and taking out their earphones, Kulzer says.

The group also talks about social interaction. Subjects include what is appropriate to discuss in the office and how office friendships can have pros and cons. For instance, although it may be great to have someone you like and get along with, if you favor that person and don’t treat everyone equally while working, it can result in hurt feelings and misunderstandings.

Kulzer also talks with group members about issues such as scheduling and making decisions independently without telling a supervisor. She uses the example of someone with ASD who takes a bus that gets them to work 15 minutes early and then assumes this means that they can also leave 15 minutes early. Kulzer explains to group members that they can’t change their schedules (or make other similar decisions) without first discussing possible options with their boss.

The group participants receive feedback from Kulzer and other instructors as they work in their internships. Together, they tackle problems that come up in the workplace and implement suggestions for improvement. Kulzer says that many of the group’s members go on to pursue associate degrees or certificates in their internship field.

 

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Additional resources

To learn more about the topics discussed in this article, take advantage of the following select resources offered by the American Counseling Association:

Counseling Today (ct.counseling.org)

Practice briefs (counseling.org/knowledge-center/practice-briefs)

  • “Autism Spectrum Disorder” by Carl J. Sheperis, Darrel Mohr and Rachael Ammons

 

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

Letters to the editor: ct@counseling.org

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Counseling survivors of human trafficking

By Lamerial McRae and Letitia Browne-James October 9, 2017

Millions of human trafficking victims exist across the globe. In the United States, hundreds of thousands of victims experience trafficking. As society expands and evolves, human trafficking perpetrators find new ways to recruit and victimize others. The evolution of perpetration ensues because of increases in accessing technology, shifting state and federal laws, and changing criminal investigation methods within communities. Human trafficking continues to evolve into a new way of enslaving human beings, stripping individuals of basic rights and freedoms, while skirting the legal issues of slavery and ownership.

Human traffickers often recruit individuals by offering the fantasy of increased happiness, stability, relationship success and financial freedom. Human traffickers, often referred to as “pimps” or “playboys,” may recruit a female or male victim with promises of a better quality of life, including, but not limited to money, security and safe shelter. These perpetrators often present as charming and recruit their victims using lies and manipulation. They prey on victims from vulnerable populations, including those with low socioeconomic status (SES), biological females, children and adolescents, immigrants and LGBTQ+ youth. The fact that these vulnerable populations often remain dependent on others or experience institutionalized marginalization allows for perpetrators to paint the picture of a better life, both in terms of finance and social support. Thus, counselors must understand the cycle of perpetration and victimization to pinpoint potential victims among clients.

As a starting point, counselors must understand the nature of the phenomenon and seek ways to identify potential risk and protective factors. Counselors must learn to assess and address possible victimization with effective rapport building and intervention. For example, youth may display delinquent behavior (e.g., truancy, sexual misconduct, drug use) as a symptom of coercion and threats by a perpetrator. Perpetrators often experience greater ease when recruiting teenagers because of their tendency to be influenced by others. Sadly, when teenagers fall victim to a human trafficker, they are subjected to the victim-blaming phenomenon.

Thus, to build therapeutic rapport from a nonjudgmental framework, counselors need to understand the true source of teenagers’ behavior rather than labeling them as inappropriate or delinquent. As counselors increase their understanding of risk and protective factors, the profession may be able to conceptualize human trafficking as a systemic problem from a broad perspective.

 

Risk and protective factors

Several risk and protective factors exist for those falling victim to human trafficking. Risk factors include the following demographics and experiences. Risk factors, which are not limited to the list provided, may change over time with the help of counselors.

  • Low SES
  • Previous or current substance abuse
  • Social vulnerability (e.g., children, females, LGBTQ+ individuals)
  • Limited education.

Protective factors, referred to as strengths in counseling, include the following demographics and experiences. Counselors must foster protective factors and strengths in clients to reduce the risk of falling victim to trafficking.

  • Education
  • Family stability
  • Strong social support networks
  • Mental and emotional health

Counselors should understand these risk and protective factors to assess potential risks for human trafficking and to focus on increasing protective factors in counseling. For example, counselors may use a family counseling approach when working with survivors to increase their connections to loved ones and family. Throughout the process of recruiting and selling human trafficking victims, counselors may notice several risk and protective factors playing a role in the process.

 

Human trafficking business model and counseling implications

Human trafficking remains a mysterious and misunderstood phenomenon. Because of a lack of understanding about the effects of human trafficking on our society, counselors are charged with educating themselves to best address and assess individuals for victimization.

Counselors should recognize that survivors of sex trafficking require additional techniques (to those used with other clients) to build rapport with them and to reduce the mistrust that they commonly have about people. To best serve survivors, treatment approaches need to remain centered on survivors, empower them, provide safety and involve a multidisciplinary approach. In addition, professional counselors working extensively with sex trafficking survivors hold legal and ethical responsibilities to provide appropriate services and identify strategies to overcome barriers to their treatment, including specialized and intensive training.

To begin, counselors must understand the human trafficking business model to conceptualize the systemic issue and the moving parts that contribute to the continuing cycle. To highlight some of the societal and professional impacts, consider the parallel of the human trafficking business model to the process of manufacturing goods. The human trafficking business model includes the following stages of grooming and distribution:

1) The supplier recruits the victim.

2) The manufacturer grooms the victim.

3) The retailer determines price and then markets the victim.

4) The retailer sells and the consumer purchases the victim.

The human trafficking business model is a sophisticated process, not always linear in nature, and it functions as a well-established industry. Thus, the need exists to explore each of the model to better understand how to help victims and break the cycle.

Stage 1: Supplying victims. The supplier, also known as the initial human trafficking perpetrator, displays high levels of mental health concerns (e.g., antisocial personality traits) and shows little concern for the basic human rights of others. When victims enter this stage, counselors may find that these individuals report troubles at home, low SES, depression, anxiety and truant behavior. These factors contribute to their need to survive. Unfortunately, this may result in a perpetrator using charm or manipulation to attract the victims. Perpetrators remove victims’ identification, passports and other valuables to trap them in the world of human trafficking.

Clinical assessment is vital at this stage and remains an ongoing process. Counselors may want to ease survivors into telling their stories, paying special attention to the therapeutic relationship. Thus, the most valuable interventions at this stage include active listening and reflection. When administering specific assessment instruments, counselors will want to measure attitudes about victimization and perpetration and prevalence rates of violence. Counselors must use both open- and closed-ended questions to directly address potential victimization. Nonverbally, counselors will want to avoid direct eye contact and limit their use of touch because of victims’ trauma and abuse history.

Stage 2: Grooming victims. This stage involves moving human trafficking victims from the supplier to the manufacturer. Perpetrators continue to display high levels of antisocial behaviors and major mental health concerns; survivors present with mental health concerns such as depression, anxiety and addiction. Substance abuse concerns usually present when perpetrators force their victims to engage in substance use to coerce and control their behaviors, often resulting in addiction.

Counselors must use clinical assessment and maintain that ongoing process. In addition, because survivors have been manufactured as a human trafficking product, their levels of abuse and mistrust often appear high when they present to counseling. Therefore, counselors must focus on the therapeutic relationship as victims provide information about their experiences in trafficking. Counselors should pay special attention to reducing the stigma of substance use and mental health concerns, especially considering that victims develop these concerns because of coercion and violence.

Stage 3: Marketing victims. This stage involves moving survivors from the manufacturer to the retailer. At this stage, human trafficking perpetrators focus on the marketing and sales aspect of their exploitation. For example, based on the quality of their goods (i.e., victim age, appearance) and market demand, perpetrators determine the price for selling each of their victims. At this stage, survivors present with major depressive, dissociative and addiction disorders.

At this stage, counselors again use clinical assessment to understand the survivor’s story while maintaining a trustworthy therapeutic relationship. As previously stated, severe mental health concerns present because of the violence and abuse that victims experience. Thus, counselors need to use evidenced-based practices to treat depression and dissociative symptoms. Some of the most helpful interventions to treat these mental health concerns include grounding and relaxation techniques.

When focusing on grounding, counselors must engage the client’s physical world to assist the person in becoming present in the moment. For example, counselors may ask clients to locate an object in the room and provide an in-depth description. Relaxation techniques to practice include deep breathing and mindfulness meditation. Both types of techniques allow clients to practice coping skills during sessions that can translate to their everyday life experiences.

Stage 4: Selling victims. As retailers push survivors toward the consumers, the perpetrators continue to focus on marketing strategies and targeting potential consumers. Perpetrators often target large events (e.g., the Super Bowl, national political conventions) to take advantage of the crowds and high demand for paid sexual services. Those paying for the sex services, the consumers, exhibit low levels of depression and anxiety. These consumers often report avoiding relationship concerns or other mental health concerns, resulting in a desire to seek out sexual activity.

Because survivors have been a part of ongoing abuse and a cycle of victimization that they cannot break, counselors must use a systemic approach to providing services. For example, counselors need to provide information on shelters and building connections with family. Counselors may incorporate the use of technology and location services, safety words and discussing location with loved ones at all times.

 

Case example         

Toney, an 18-year-old multiracial, cisgender male, moved away from his caregivers’ home about one year ago and currently lives with a friend. He moved because of safety issues in his home and within the nearby neighborhood. When Toney was 16, his father died during a gang-related shootout at their home. Thus, Toney often felt afraid of engaging in a similar lifestyle and enduring similar consequences. Toney’s mother suffered from a severe substance use disorder that led to eviction from their rental home because she could not afford the rent. Toney and his mother became homeless.

While Toney was homeless, Kevin, a childhood friend, suggested that Toney come live with him temporarily as long as Toney obtained a job and contributed to the rent and utility bills. One day, Toney answered the front door, and a young adult male appearing to be about Toney’s age attempted to sell him a magazine subscription. Toney disclosed to the salesman that he was financially strapped. The young man told Toney about the large sums of money he made while selling magazine subscriptions and offered to put him in contact with the owner. Toney was intrigued by the idea of alleviating his financial troubles, and the young male immediately scheduled a meeting with the owner for later that night.

That evening, Toney met with the young salesman and the business owner in an abandoned parking lot, bought their sales pitch and decided to go to work. The business owner told Toney that he would need to move six hours away to another state because there was a high demand for work there and he would not have to pay any rent or utility bills. The business owner promised Toney the opportunity to travel and see many areas of the country while working in the job.

Thus, Toney left a day later to live in a weekly hotel in a new city with his new manager and several others. Upon arriving, the manager took them to a warehouse to pick up the product. They all began working the next day.

After a few weeks, Toney began grasping the reality of his situation. The job of trying to sell magazine subscriptions was strenuous and exhausting. He often worked 10- to 12-hour days while receiving limited rest and food. When Toney voiced concerns about the number of work hours he put in each day, his manager threatened him. The threats later escalated to physical assault when Toney again voiced his concern and when the manager perceived him to be underperforming at the job.

No matter how hard Toney tried, he could not meet the daily sales goal that the manager set for employees. When Toney failed to meet the daily sales quota, the manager either denied him his nightly meal or forced him to sleep outside of the hotel on the streets. As a result, Toney rarely ate and often did not receive the money he had earned while working. He was told that he would receive the money once the team had completed its sales goals for the area and had moved on to another city.

One day, while trying to sell magazines to a homeowner who declined to buy anything, Toney became agitated and started crying. He told the homeowner that he was in trouble and begged her to help him get home, across state lines. The homeowner had recently watched a documentary on human trafficking and invited Toney to use her phone to call the authorities.

The police arrived and took Toney’s statement about his work experiences. Fortunately, the responding officer had recently attended a departmental training on human trafficking, and she took Toney to the police station for further questioning and support. The officer connected Toney with a local nonprofit organization that provided multidisciplinary services, including professional counseling, to survivors of human trafficking. The organization offered shelter and provided Toney with career development services to help him obtain legitimate work. The shelter’s ultimate goal was to move Toney back to his hometown.

In counseling sessions with Toney, the counselor focused on direct questions to assess the nature of the human trafficking Toney had experienced. For example, “Did anyone threaten you or your loved ones?” and “Did you have difficulty leaving the work that you did selling door-to-door merchandise?” While initially reluctant, Toney eventually responded with answers that indicated his victimization. For example, he reported that his manager used threats and power and control tactics (such as denying Toney food, money and shelter) to force him to work.

Following assessment, Toney received counseling services focused on recovering from the abuse he had endured. Toney felt validated because he was not alone while accepting that he had fallen victim to human trafficking. The counselor and Toney focused on crisis intervention and stabilization in the beginning, which included discussions about adjunct services and basic needs assessments (e.g., food and clothing, job obtainment). Next, the counselor and Toney addressed the trauma, focusing on decreasing anxiety-provoking cues and scaffolding into addressing more severe cues and triggers. All the while, Toney and the counselor developed several grounding and relaxation techniques to use both in their sessions and in Toney’s real-world experiences.

One of the most valuable grounding techniques made use of a rock that Toney could hold whenever he felt distressed. The counselor taught Toney how to become present, while holding the rock, through discussions about the texture, shape and weight of the rock. Discussing these tactile experiences allowed Toney to focus on the here-and-now rather than attempting to escape feelings and thoughts.

Toney and the counselor also used a breathing method in which Toney would take a deep breath through his nostrils for at least three seconds and exhale through his mouth for three seconds. They determined that he needed to take at least three deep breaths during the exercise so that he could calm down.

In the final stages of counseling, Toney and the counselor developed an action plan to help him avoid falling victim to trafficking. That does not mean, however, that Toney took responsibility for the actions of others. Toney and the counselor reviewed the different needs he may have and how to meet those needs in a helpful manner.

While focusing on the trauma from human trafficking victimization, the counselor worked with Toney on obtaining a job at a local fast food restaurant. They chose this restaurant so that he could easily transfer to another store in his hometown once he felt comfortable with the transition. After three months, Toney finally returned home and moved back in with his friend, Kevin. He remained employed as a fast food line cook and began seeking education at a local culinary institute.

 

 

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Lamerial McRae is an assistant professor at Stetson University and a licensed mental health counselor in Florida. Her research and clinical interests include counselor identity development and gatekeeping; adult and child survivors of trauma, abuse and intimate partner violence; marriages, couples and families; LGBTQ issues in counseling and human trafficking. Contact her at ljacobso@stetson.edu.

Letitia Browne-James is a licensed mental health counselor, clinical supervisor and national certified counselor. She is a clinical manager at a large behavioral health agency in Central Florida and is in the final year of her doctoral program at Walden University, where she is pursuing a degree in counselor education and supervision with a specialization in counseling and social change. She has presented at professional counseling conferences nationally and internationally on various topics, including human trafficking.

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

 

Coming to grips with childhood adversity

By Oliver J. Morgan September 7, 2017

Counselors and mental health professionals of all stripes are coming to understand the prevalence of childhood adversity, toxic stress and trauma in our caseloads. Barely a day goes by that we do not see someone with a trauma history, whether we are aware of it or not. Some have even called for universal trauma screening of all clients and patients as an ethical responsibility, especially for those individuals who are more at risk, including first responders, military personnel, refugees, those with serious medical and chronic illness, and people struggling with addiction. It would help to know what we are dealing with upfront.

I became aware of a duty to inquire about trauma in 2007 when I began the Supportive Oncology Service (SOS), a psychosocial counseling practice colocated in a medical oncology setting. I had been teaching, practicing and publishing mostly in addiction studies at the time, but I was hungering for change in my own clinical work. When the opportunity to work alongside physicians and learn about serious medical illness came along, I jumped at it. Quickly, I discovered that what I was learning about the interface between addiction and trauma could just as easily be applied to the occurrence of trauma in a cancer-involved population. This cross-fertilization of ideas and their practical outcomes has been a rich source of learning for me.

The Adverse Childhood Experiences (ACE) studies, a collaborative project between Kaiser Permanente and the Centers for Disease Control and Prevention (CDC), instigated my interest. The ACE project was designed to study long-term relationships between adverse experiences in childhood and adult health and behavioral outcomes. I had begun looking into this as an offshoot of my addiction work but promptly came to realize its applications in the general population. The initial studies were conducted from 1995 to 1997 with 17,000 ordinary Americans in a large outpatient medical clinic and now have been replicated across a number of states and even internationally.

Since its inception in 1995, numerous papers have been published by the ACE project that present the evidence for consistently strong and graded relationships between adverse experiences in childhood, household dysfunction and a host of negative health outcomes later in life. Many of the most serious illnesses facing our country — heart disease, cancers, chronic lung and liver disease, a host of autoimmune disorders, obesity, substance-related and addictive disorders — as well as a variety of health-risk behaviors, including smoking, use of illicit drugs, high numbers of sexual partners and suicide attempts, are strongly related in a dose-response or graded fashion to childhood adverse experiences.

This suggests that the impact of adverse childhood experiences on adult health status and adult suffering more generally is powerful. Dose-response relationships indicate a change in outcome (e.g., harmful substance use or ischemic heart disease) that is associated with different levels of exposure to a stressor. Experiencing multiple categories of trauma in childhood increases the prospects for later illness. ACE studies measure the number of categories of exposure and not the number of instances; for example, one instance or multiple instances of sexual assault would count as one category. If anything, this underestimates a person’s exposure to adverse experiences.

Researchers are finding that the occurrence of adverse experiences is quite common in all populations. Relationships found in the original population are being replicated elsewhere. Fifty-two percent of those participating in the original study acknowledged at least one category of adversity in childhood. Eighty-seven percent of those who acknowledged one adverse childhood experience also experienced additional adversities. The study revealed that adverse experiences occur in clusters, with 40 percent of the original sample reporting two or more categories of adversity and 12.5 percent experiencing four or more categories of adversity.

The ACE categories are as follows:

  • Physical abuse
  • Sexual abuse
  • Emotional abuse
  • Physical neglect
  • Emotional neglect
  • Mother is treated violently
  • Loss of a parent for any reason
  • Mental illness in the home, including suicidal behavior or institutionalization
  • Substance abuse in the household
  • Criminal behavior in the household, including incarceration of a household member

‘Mild’ adversities?

What first strikes people when they review the categories above is how different the list seems from what we expect. It challenges our assumptions. Many of us are familiar with the standard understandings of trauma connected to natural or human-made disasters, battlefield experiences, violence or sexual assault. Clearly, these are life-altering events. Although these categories are on any list of traumatic events, so are forms of household dysfunction, neglect, and emotional abuse and humiliation. We are coming to understand that, when dealing specifically with children, a wider range of traumatic experiences can be equally devastating and produce debilitating outcomes years later. Further studies are also uncovering negative outcomes related to more “ordinary” adversities such as accidents, childhood hospitalizations or the loss of a sibling.

The ACE results had suggested that the different categories were essentially equal in their damage. This was startling. However, ongoing trauma science supports this conclusion. Although some categories of adversity stand out because of the social significance and stigma attached to them, we now know that more hidden or subtle adversities, such as neglect and experiences of recurrent humiliation by a parent, can both be detrimental in the present and carry long-term consequences for adult health and psychiatric illness. Scientists such as Martin Teicher and his colleagues at Harvard University have documented the potent negative effects of parental verbal aggression and emotional maltreatment.

More common adversities can have large impacts on children. The clinical and research focus on posttraumatic stress disorder may have slanted our expectations, giving us the impression that adversity comes only with high-profile suffering. If it doesn’t leave a mark, it can’t be all that damaging, right? In reality, nothing could be further from the truth.

In short, poor health and risk for illness — medical as well as psychiatric — can be rooted in childhood psychosocial experiences. They can also be hidden due to time, denial and social taboo. The ongoing ACE studies and allied research have given us a new lens for viewing health, wellness and disease. This is nothing short of revolutionary. It is instructive that this new vision has been picked up by the Center on the Developing Child at Harvard University and the American Academy of Pediatrics. Programs for medical education, intervention and prevention are being developed by these groups and others.

Looking at cancer

In 2010, one of the ACE papers made the dose-response link to risk for lung cancer. This got my attention. Adverse childhood experiences are obviously not the only causes of cancers — disease is often multicausal. However, the associations this paper made between having a history of adverse childhood experiences and those who were first hospitalized at younger ages with lung cancer and died prematurely at younger ages from lung cancer were striking. Smokers were much more likely to have a history of adverse childhood experiences than were nonsmokers. In addition, those with adverse childhood experiences were more likely to begin smoking at younger ages than were other smokers.

I was amazed until I went back and did a chart review for my small oncology service. At that time, we had seen about 100 patients. Admittedly, this was a potentially skewed population, but even so, 60-70 percent of our patients with a variety of cancers met the ACE criteria for adverse experiences, and a large proportion of them had multiple ACE categories in their past. Research had suggested that those with four or more categories of childhood adversity were likely to be diagnosed with cancer or some other serious illness. Those with six or more categories had a life expectancy shortened by up to 20 years. My patient population buttressed those numbers. In addition, several of my patients who were not smokers but nevertheless were diagnosed with lung cancer did have a history of trauma. That day I became a believer in universal screening for trauma in my population of cancer patients. My colleagues and interns have also become believers.

When I discussed these outcomes with several of my physician colleagues, they quickly came to the conclusion that because childhood adversity was strongly associated with the risk of early smoking — nicotine is a powerful anti-anxiety agent — that would likely explain the prevalence among patients with lung cancer. Case closed. If a cancer patient also had a traumatic childhood history, smoking was the likely pathway from trauma to lung cancer. Risky behavior led to later disease.

This did not sit well with me, however. First, it did not explain the high trauma numbers in my cancer patients more generally (a number of whom were nonsmokers) and, second, identifying only this pathway seemed too facile. I believed that more was involved.

Changes that make us vulnerable

At first blush, ascribing disease to risky behaviors and poor lifestyle choices seems reasonable. There is obviously some truth to it. Lots of scientific evidence points to smoking as a risk for cancer. Still, I wondered, could there be other pathways from childhood adversities to cancer? The connections seemed clear, but what were the explanations? As an addiction specialist, I was suspicious of the “poor choices” explanation. Were there other, hidden dynamics that were not so obvious?

This is where the intersection of childhood adversity and neurobiology becomes so important. As a counselor, I had focused my thinking on the social and psychological explanations. Childhood adversity short-circuited psychosocial development. Trauma created toxic stress in a person’s life. Negative experiences became part of a person’s sense of self and view of the world, which made living difficult. These negative experiences also placed emotional burdens on the person’s psyche and spirit, creating negative internal images, expectations and attachments at the core of the personality. People learned to be wary of others and became more guarded, isolated and distrustful. Fair enough. But how do we get to physical disease?

This move requires an alchemical kind of insight — namely that the footprints of our psychosocial experiences of attachment and caregiving are inscribed into our brains and bodies in what Allan N. Schore, Daniel J. Siegel and others call “psychobiological” experiences. Donna Jackson Nakazawa, in her 2015 book Childhood Disrupted, described it this way: Biography becomes biology.

We are continuing to learn about the depths of this process. From our earliest beginnings, experience shapes the development of our brains, bodies and critical survival systems. The formation of our neural architecture, emotional and cognitive networks, regulatory systems, coping and stress response, and immune systems depends on the kinds of caretaking we receive. Social networking is part of our DNA it seems; it is essential for our survival but can also create vulnerabilities.

In childhood, all the essential systems are forming and developing. When children are caught in cycles of abuse, neglect or humiliation, their stress response and coping mechanisms can be degraded and become stuck in the “on” position. Their bodies are continually bathed in inflammatory stress chemicals. This can lead to physiological changes, long-lasting inflammation, eventual breakdown and disease. The immune system can be weakened, even at the level of genes. Neuroscience is helping to document these enduring kinds of changes, large and small, that are the pathways to later illness.

Another form of negative development that can follow from childhood adversity affects the child’s regulatory coping mechanisms for stress. This can lead to difficulties such as substance use and addictive disorders. Emotional and behavioral regulation are essential skills, built upon the foundation of neurological development. Toxic stress, however, can alter and “miswire” the development of critical coping systems, resetting their baseline levels of activity and making them supersensitized, not only to stress but also to triggers that signal the approach of rewarding or stressful situations. In these instances, individuals may substitute chemical or behavioral forms of coping, reward, relieving stress or alleviating anxiety and pain. Regularly resorting to such substitutes can ingrain these choices into neural channels that are resistant to change once firmly set.

These ways of thinking have opened my eyes. Childhood maltreatment and adversity alter children’s brain development and create the underlying conditions for short-term coping and long-term medical and psychiatric problems, including cancers and addiction. The intersection of knowledge from developmental psychology, attachment theory, trauma and neuroscience is presenting us with many new ways to conceptualize the challenges that confront us. As counselors, it is imperative that we remain open to these new developments.

Recommendations

Based on my experience, I want to make some practical recommendations:

1) Counselors need to learn all we can about adverse childhood experiences and their impact on adult living.

2) We can all benefit from universal screening for adversity and trauma as a first step in clinical work. A few simple questions can be added to our standard history taking. Asking these questions on an abstract or computerized form, followed up with face-to-face conversation, has been found to be the best practice for obtaining accurate information. There may be direct health benefits to these conversations. As reported in Nakazawa’s book Childhood Disrupted, physicians who discussed adverse childhood experience questions with patients following completion of intake forms found a 35 percent reduction in office visits and an 11 percent reduction in emergency room visits for patients with chronic ailments over the ensuing year.

3) When we discover a history of adversity, we should remain curious, be empathic and be predisposed to believe. The primary consideration initially is creating a safe space.

4) Be prepared for pendulum swings in the conversations. It is normal to move forward in the story and then back off when the client shows anxiety.

5) Teach grounding techniques so that the client can retreat to safety when overwhelmed.

6) As is the case in much of our counseling work, self-knowledge is critical. Each of us can benefit from conducting our own self-assessment of adversity and trauma. Understanding our own issues and working with them may be the most important first step in recognizing the problem and then working with others.

Good luck. This work, I believe, is one of the greatest secrets and potential resources in clinical practice today. Trauma continues to be a hidden occurrence among our clients and patients for too many counselors, physicians and human service providers. We need to do better.

 

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Oliver J. Morgan is a professor of counseling and human services at the University of Scranton in Pennsylvania. He is beginning his 27th year at the university and is completing a book titled Hungry Hearts: Unlocking the Secrets of Addiction and Recovery. Contact him at oliver.morgan@scranton.edu.

Letters to the editor: ct@counseling.org

Counseling Today reviews unsolicited articles written by American Counseling Association members. To access writing guidelines and tips for having an article accepted for publication, go to ct.counseling.org/feedback.

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

’13 Reasons Why’: Strengths, challenges and recommendations

By Laura Shannonhouse, Julia L. Whisenhunt, Dennis Lin and Michael Porter September 4, 2017

The Netflix series 13 Reasons Why has launched a national discussion regarding teen suicide, motivating a webinar response from professional organizations about how to shape the dialogue, dozens of editorials and millions of cautionary letters home from schools to parents across the country.

The series, based on a novel, is narrated by high school student Hannah Baker, who made a series of cassette tapes to be passed to 13 individuals she argues contributed to her reasons for dying. Her story is seen through the eyes of a peer, Clay, who listens to the tapes. He comes to understand Hannah’s perspectives about those people and events she claims motivated her suicide, which include Clay’s own (in)actions.

The series has been critically acclaimed for the acting and commended for addressing challenging topics, such as bullying/cyberbullying, sexual assault and teen suicide. However, school administrations, school counseling associations, suicide prevention organizations and counseling/psychology associations such as the American Foundation for Suicide Prevention (AFSP), the Suicide Prevention Resource Center (SPRC), the American School Counselor Association (ASCA) and the National Association of School Psychologists (NASP) have advised caution because of the graphic nature, revenge fantasies and potential contagion effect. This article highlights strengths and major challenges of the series. It also provides recommendations that have been underrepresented, though not absent, in the discussion.

 

Strengths

1) Raising awareness that suicide is a real problem.

According to the Centers for Disease Control and Prevention (CDC), suicide is a major public health issue. The most recent  statistics available note that among high school students, 17 percent have seriously considered suicide, while 8 percent have attempted suicide within the past 12 months. We know that for every suicide, there are many survivors, including the family and friends of the person and those who have experienced psychological, physical and social distress after exposure to a suicide.” The most commonly cited statistic is that each suicide directly affects six people; however, more recent research argues there are between 45 and 80 survivors per suicide.

In 2015, there were more than 44,000 reported suicide deaths, including 5,191 deaths by suicide among those ages 15 to 24. However, this statistic includes only those that were reported. Although there is no consensus on the rate of under-reporting due to stigma or ambiguous cause of death, the best analysis suggests that for each completed youth suicide, there are 100-200 times as many nonfatal suicide actions.

Combining CDC data with our current understanding of rates of suicidal ideation in youth, in this moment there are close to 15 million people in the U.S. who think of suicide in any given year. Suicide is a very real public health issue; when it is ignored, stigmatized or minimized, we as a community are missing the chance to prevent it.

2) Even professional counselors may not be ready to respond to a suicidal situation.

Because counselors often receive referrals of clients who are suicidal, counselors’ competency in identifying and intervening with those at risk is crucially important. However, the overtaxed counselor in 13 Reasons Why, Mr. Porter, is underprepared to face a suicidal student coping with complex trauma. Although he did not act in the scope of best practice, his failings are unfortunately not unusual among counselors, despite decades of advocacy for increased suicide assessment trainings in counselor education.

Mr. Porter missed several suicidal statements (e.g., “I need everything to stop”), made assumptions about contributing events and was uncomfortable talking about suicide (and other issues). We may easily judge Mr. Porter’s mistakes, but as counselors, we should take this opportunity to reflect and ask ourselves if we are ready to respond to a student at risk of suicide. The research is equivocal.

3) Suicide is complex and individual.

Although 13 Reasons Why portrays some known “red flags” that can indicate suicidal intent, the factors that contribute to individual suicides vary. Stressors that may influence one person’s decision to die by suicide may not have the same effect on others. For instance, we know that not all people who are depressed die by suicide (research shows the rate is from 2-15 percent) and that not all people who complete suicide are depressed. There is a variety of prevention programming regarding common warning signs. However, there is no perfect amalgam of warning signs or demographics (e.g., risk for transgender persons) that helps us differentiate who will decide to die by suicide. We need to go beyond just learning warning signs in order to help.

Livingworks, a suicide intervention training organization, focuses on three elements when assessing warning signs and risk factors. First, we must look for the meaning behind stressful events. For instance, in 13 Reasons Why, being listed “Best Ass” was highly distressing to Hannah because she felt objectified and was concerned people would misperceive her to be easy. However, another student, Angela “Best Lips” Romero, was flattered by such attention. The meaning behind the stressful event is more important than the stressful event itself.

Second, we need to know that warning signs can be, and often are, expressions of pain. When Hannah pushed Clay away, he recognized that something was wrong but did not see that her rejection was an indication of emotional pain. Third, we must trust our intuition. One peer recognizes Hannah’s poem as a cry for help but does not offer assistance. We need to pay attention to our gut feelings and act on them to take care of each other.

13 Reasons Why provides an opportunity to see Hannah’s experience of several traumatic events (cyberbullying, being stalked, public objectification, losing money, feeling responsible for a person’s death, witnessing rape and being raped) and does a good job of depicting the pain, shame and isolation she experiences as a result. The viewer has an opportunity to consider Hannah’s subjective experience and understand how the cumulative effect of these “reasons why” motivates her to suicide.

One model to help contextualize suicidality is the interpersonal-psychological theory of suicidal behavior developed by psychologist Thomas Joiner. Joiner states that the highest risk occurs when one feels like a burden to others, feels alienated or lacks belongingness and, crucially, has overcome the natural human inclination toward self-preservation. This model posits that suicide is a process — one gradually builds tolerance to the idea through self-injurious thoughts or behaviors (although each person’s path is unique). There are multiple points on that path at which others can intervene. The 13 Reasons Why series emphasizes those missed opportunities. As in Hannah’s case, every day there are suicides that happen as a result of those missed opportunities.

4) The central message is a positive one.

In the last episode, Clay says to Mr. Porter, “It has to get better, the way we treat each other and look out for each other.” Instead of feeling guilty or turning away, we can task ourselves with being more supportive community members.

All too often, we operate from a place of fear, which is understandable considering that schools have a legal duty to protect students from self-harm, and lawsuits are a potential reality (as shown in 13 Reasons Why). However, when systems or individual responders act out of fear, it focuses the interaction away from the needs of the person at risk. Even well-intentioned modern practices of “suicide gatekeeping” have substituted swift (and protocol-driven) identification and referral for the direct supportive intervention by community members proposed by John Snyder in 1971. Clay’s words echo those from Snyder half a century ago, when he said that most “who attempt suicide are victims of breakdowns in community channels for help.”

Although Mr. Porter clearly failed to proper identify Hannah’s suicidal ideation, perhaps even more troubling was his failure to hear her story and understand the factors behind her decision to die by suicide. Listening and demonstrating empathy to someone who is struggling was demonstrated to reduce suicidal ideation on calls to the National Suicide Prevention Hotline. Talking about suicide can help the person at risk to no longer focus on the past or feel alone and, instead, shift to the present moment, where the person can feel understood and cared for. If those in Hannah’s community who were witness to her emotional pain had actively engaged her and listened, it may have reduced her isolation and lessened her self-perception as a burden. This may even have prevented Hannah’s death.

Research indicates that our personal beliefs about suicide influence our responder behaviors. Therefore, gaining awareness of our beliefs and how our ability to intervene is affected by them is vital. Regardless of whether we can stop a suicide, we can control how prepared we are to try. We can make sure that our systems (in schools and elsewhere) are places where it is easy for someone to receive help.

After working through Hannah’s tapes, Clay now believes that we are, in a way, our brother’s keepers. Community-level response by direct intervention is a central theme in my (Laura Shannonhouse) research. It involves equipping “natural helpers” (e.g., teachers, bus drivers, resources officers, school counselors/psychologists) with the skills needed to perform a life-assisting suicide intervention at the moment it is needed most.

The producers and cast of 13 Reasons Why have underscored their desire for this series to start a conversation. Although that has certainly been accomplished, we hope the dialogue focuses more on how we can “look out for one another” and foster communities less at risk for suicide.

 

Challenges

1) Graphic nature and contagion

Viewers of 13 Reasons Why watch two rape scenes and Hannah’s suicide, which is shown in detail. Nic Sheff, one of the writers of the series, stated that the scene of Hannah’s suicide was intended “to dispel the myth of the quiet drifting off.” Some crisis texts suggest that we “deromanticize” suicide by helping our clients understand the unintended effects of trying to die by suicide, such as surviving but becoming disabled or alienating friends and family. Therefore, an argument could be made that a graphic, painful portrayal of suicide is warranted.

However, research does suggest that suicide portrayals can contribute to contagion by triggering suicidal behaviors in people — particularly youth — who are experiencing high levels of emotional distress. In fact, SPRC and AFSP have made recommendations for best practices in prevention of suicide contagion. A discussion of post-suicide intervention to prevent contagion is beyond the scope of this article, but as an example, the locker memorial portrayed throughout the series is against standard guidance (it should not last for weeks, as shown). Furthermore, when considering how media reaction to the series has often included sensational headlines, it is helpful to review these recommendations for reporting on suicide.

2) Survivor’s guilt and revenge fantasies

By assigning “reasons why,” the series sends a message that Hannah’s death is caused by other people’s actions. When Clay openly questions, “Did I kill Hannah Baker?” his friend Tony answers dramatically, “Yes, we all killed Hannah Baker.”

Although we suggested earlier that we all have a responsibility to create communities that help prevent suicide, Tony’s level of direct attribution can be counterproductive. Hannah experienced multiple losses, traumas and stressors caused by others, both intentionally and unintentionally. Placing responsibility for her death on those individuals instead of on Hannah’s action can exacerbate survivors’ guilt. Those viewers who have lost a friend, loved one or acquaintance to suicide may feel even more strongly after viewing the series that “It is my fault.”

These feelings are associated with lower functioning in comparison with survivors of accidents. Although undeserved, survivor’s guilt is a real phenomenon, and considerable research shows that even counselors who experience the death of a client by suicide can experience shame/embarrassment and emotional distress.

Whereas Clay may feel guilt for his part in Hannah’s story, the tapes could implicate others in criminal or negligent behavior, perhaps giving Hannah posthumous revenge. Some viewers who may have struggled with suicidal ideation themselves could get the message that if they take their lives, they can get revenge on those who have hurt them. This is an additional reason that schools across the nation and professional helping organizations have felt the need to do damage control for 13 Reasons Why.

 

Recommendations

1) Parents need to not just talk but watch, listen and connect.

Some school counselors argue that it’s harmful for children and teens to watch the series on their own without the support of a parent or trusted adult because the series depicts a graphic and romanticized portrayal of a teenager in crisis and does not identify competent resources capable of helping her. Accordingly, many experts encourage parents to talk to their children about the series. In addition to using talking points, we recommend that parents listen deeply and without judgment to what their children say. When people feel genuinely heard, they are more likely to talk about their true thoughts and feelings.

To accomplish this goal, parents can use active listening skills, such as open-ended questions, reflections of feeling, paraphrasing and encouragement. Also, we recommend that parents watch the series and risk being human — risk being impacted by the series and empathizing with their child. The construct of empathy is powerful, particularly if it is sincere. For a three-minute visual summary, consider watching Brene Brown on empathy. In our counseling skills courses, we often talk about “getting in the well of despair” and genuinely connecting with others. We know that talking about suicide paradoxically provides a significant buffer to suicidal action.

2) We need more than prevention programming in schools.

We know from a well-regarded U.S. Air Force study that we need suicide programing at all three levels: prevention, intervention and post-intervention. Many suicide prevention programs have been implemented in the school context, but there is mixed evidence of their effectiveness. From our clinical experience in crisis response, our scholarship and our history with training a specific model of suicide intervention, we need to acknowledge that we are biased about what types of programming should be implemented and when is the right time to implement. We feel that an appropriate first step for a school system is to implement basic screeners and gatekeeper trainings such as Signs of Suicide or Sources of Strength.

However, suicide prevention should not end with identification for referral. Optimally, the process continues by assessing level of risk, identifying reasons for dying and reasons for living, discussing alternatives to dying, enlisting the support of trusted loved ones and limiting access to lethal means or securing the person’s environment. Because youth who struggle with thoughts of suicide often seek out the support of those they trust rather than professional mental health providers, those teachers, coaches and others with open hearts and doors are the most effective gatekeepers for a system. Their nondirection and empathy are useful pedagogical qualities and vital to effective suicide intervention.

We endorse models that empower those “natural helpers” to provide a potentially life-saving intervention for students who are in suicidal distress. Although this may be augmented with the support and follow-up of a trained mental health provider, gatekeepers can implement the steps listed above.

3) Be intentional about identifying caregivers and shifting school culture.

My (Shannonhouse) research involves partnering with school districts and superintendents (in Maine and Georgia) to identify “natural helpers” and equip them with the skills to perform a life-assisting intervention in the moment (i.e., Applied Suicide Intervention Skills Training, or ASIST). These natural helpers are often teachers, resource officers, coaches, administrative staff, bus drivers and other people who are likely to be confidants to students who experience distress. Measuring suicide intervention skills and responder attitudes is easy for an academic. Identifying those school personnel in the trenches who would be first responders is more difficult — it requires the total involvement of administrators. Furthermore, such an approach requires schools to commit to a student-centered response model.

ASIST is relationship-driven and aligned with the values of the helping professions. It meets the needs of students who are at risk by focusing on responding to those immediate needs rather than referring the student (which can lead to further isolation and an increased sense of burdensomeness). Although the student is often referred for more long-term counseling, ASIST provides the student with a six-step intervention at the moment it is most needed and can be performed by anyone over age 18. Having natural helpers trained in ASIST or a similar protocol can dramatically increase a school’s responsiveness and effectiveness to help students in distress.

4) Use an intervention model backed by research.

ASIST is a 14-hour, two-day, internationally recognized and evidence-based model that has been adopted by multiple states and the U.S. Army. It has also been recognized by the CDC and used in crisis centers nationwide. Caregivers trained in ASIST consistently report feeling more ready, willing and able to intervene with a person at risk of suicide.

The program has been evaluated in a variety of settings (click to download), with pretest to post-test improvement noted in trainees’ comfort level at intervention and in their demonstrated intervention skills in response to simulated scenarios. Although outcome research is rare, research compared ASIST-trained counselors with those trained in other models through a double-blind, randomly controlled study of more than 1,500 calls to the National Suicide Prevention Lifeline. Those trained in ASIST more often demonstrated particular behaviors such as exploring invitations, exploring reasons for living, recognizing ambivalence about dying and identifying informal support contacts. Those trained in ASIST also elicited longer calls.

We found that ASIST can be applied to both university and K-12 settings. Our work measured increased suicide intervention skills and beneficial responder attitudes, which have been maintained over time. We have trained more than 500 people in ASIST and have received multiple reports of teachers disarming fully formed suicide plans with their new skills. More recently, we have conducted behavioral observations of ASIST responder behavior and have begun evaluating outcomes of students who have received ASIST intervention. Initial results have been promising, including better coping and commitment to follow-up and decreased lethality.

 

Summary

Although 13 Reasons Why gives us pause for its poor portrayal of effective suicide intervention, we feel that the series raises awareness and, at its core, advocates a community-level response to suicide prevention. This message to “look out for each other” is aligned with more intervention-oriented gatekeeping. We have explored the impact of one such model, ASIST, in several educational settings and found that it improves responder behavior. Furthermore, this approach comes with a mindset that systems can harness their strengths (i.e., natural helpers) to focus on responding to and intervening with the student rather than simply identifying and referring the student to the system.

 

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Please contact me (Laura Shannonhouse) should you have any questions about our research.

 

 

Laura Shannonhouse is an assistant professor in the Counseling and Psychological Services Department at Georgia State University. Her research interests focus on crisis intervention and disaster response, particularly involving social justice issues in this context. Currently, she is conducting community-based research in K-12 schools (suicide first aid) to prevent youth suicide and with disaster-impacted populations in fostering meaning-making through one’s faith tradition (spiritual first aid).

 

Julia L. Whisenhunt is an associate professor of counselor education and college student affairs at the University of West Georgia. She specializes in the areas of self-injury, suicide prevention and creative counseling. She is particularly interested in the relationship between self-injury and suicide and ways that mental health professionals can apply this knowledge to clinical intervention.

 

Dennis Lin is an assistant professor at New Jersey City University, with areas of expertise in play therapy, child/adolescent counseling and assessment, suicide prevention/intervention, quantitative research and meta-analysis. He is also a certified master trainer of Applied Suicide Intervention Skills Training (ASIST).

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

FASD: A guide for mental health professionals

By Jerrod Brown July 10, 2017

Fetal alcohol spectrum disorders (FASD), which researchers have estimated affect 2 to 5 percent of the U.S. population, are lifelong conditions that result from exposure to alcohol in utero. Kenneth L. Jones, David W. Smith and colleagues are credited with discovering the birth defects and long-term impacts on cognitive and social functioning caused by fetal alcohol syndrome in 1973.

Prenatal alcohol exposure can result in a host of issues related to:

  • Cognitive functioning (e.g., impulse control, attention, executive functioning)
  • Social functioning (e.g., communication skills, recognition of social cues)
  • Adaptive functioning (e.g., problem-solving, ability to adapt to new situations)

Furthermore, several neurological issues characterize FASD, including stunted cell and nerve growth, elevated rates of cell mortality, neurotransmitter interruptions and migration issues in organic brain growth. Complicating matters, the overwhelming majority of individuals with FASD experience an array of psychiatric disorders, increasing the likelihood that these individuals will need specialized services from mental health care providers.

Unfortunately, many of these providers and professionals lack the necessary training and expertise to accurately identify and effectively treat the unique and complex symptomatology of this population. The goal of this article is to provide a basic introduction of FASD to mental health professionals in six key areas: FASD symptoms, diagnostic comorbidity, memory impairments, tips for interacting with individuals who may have FASD, screening and assessment, and treatment.

FASD symptoms

A diverse range of symptoms characterizes FASD.

Executive functioning deficits: Impairments associated with executive functioning are a hallmark deficit of FASD, impacting the majority of individuals affected by these disorders. Executive functioning deficits are often associated with impulsivity, diminished ability to learn from consequences and impairments in planning, verbal reasoning, emotional regulation, memory and learning.

Social skills deficits: Individuals with FASD often have pervasive impairments in the domain of social functioning. Misinterpretation of social cues is not uncommon. This can lead to boundary violation concerns (e.g., inappropriately touching another person), which can in turn result in involvement in the criminal justice system. Such social skill deficits can also increase the individual’s level of vulnerability to manipulation by others and an inability to detect unsafe situations and people.

Attachment problems: Consistent with these deficits in social skills, poor attachment with the primary caregiver is relatively common in children with FASD. Poor attachment with the primary caregiver can increase the likelihood of misdiagnosis in a child. Common misdiagnoses may include attention-based (e.g., attention-deficit/hyperactivity disorder [ADHD]) or behavior-based disorders (e.g., conduct and oppositional defiant disorders). In fact, it is not uncommon for these disorders to co-occur with a diagnosis of FASD. Given that reality, mental health professionals who work with individuals impacted by FASD should familiarize themselves with commonly co-occurring disorders such as those just mentioned.

Adaptive functioning: Adaptive functioning involves an individual’s practical, social and mental capacities to deal with everyday challenges and problems (e.g., personal hygiene, personal finances, navigating social interactions). In light of the executive functioning problems outlined earlier, as well as struggles with processing abstract information and solving problems, individuals with FASD have difficulty in the realm of adaptive functioning. The consequences can range from difficulty maintaining employment to struggles with caring for one’s self. Because of these deficits in adaptive functioning, a high percentage of individuals with FASD are dependent on the support of family and social services.

Learning problems: One of the key issues related to adaptive functioning among individuals with FASD is difficulty learning from past experiences. Furthermore, individuals with FASD often struggle to use past experience to prospectively avoid dangerous people and situations. These deficits are exacerbated by impulsivity and an inability to think strategically about decisions. Hence, FASD affects an individual’s ability to understand society’s norms and to behave within those norms.

Diagnostic comorbidity

Increasing the likelihood of negative short- and long-term outcomes, individuals with FASD often have co-occurring disorders and other issues.

Diagnostic comorbidity: It has been estimated that the overwhelming majority of individuals with FASD experience comorbid psychiatric conditions. ADHD is the most prevalent comorbid disorder observed among those affected by FASD. Other disorders frequently observed among adolescents with FASD include conduct disorder and oppositional defiant disorder. Finally, individuals with FASD are also at an elevated risk to abuse substances later in life.

Physical complications: A number of physiological symptoms can suggest the possibility of FASD. For example, prenatal alcohol exposure can result in cardiovascular (e.g., septal defects, hypoplastic pulmonary arteries) and kidney (e.g., pyelonephritis, hydronephrosis, hypoplasia) irregularities. Prenatal alcohol exposure has also been linked to orthopedic irregularities in the structure of bones in the upper body (e.g., radioulnar synostosis), fingers and toes (e.g., camptodactyly, brachydactyly, clinodactyly).

Other brain-based injuries: Individuals with FASD may be more prone to traumatic brain injuries throughout the life span. This could contribute to the underdiagnosis and misdiagnosis of FASD. Furthermore, these traumatic brain injuries may exacerbate other secondary conditions, including ADHD, executive functioning impairments, mental health and substance use disorders, and so on.

Other life adversities: As a function of FASD and these other co-occurring disorders and impairments, individuals with FASD are disproportionately likely to be afflicted with problematic life experiences. For example, individuals with FASD often come from unstable homes, experience neglect and abuse (verbal, physical or sexual), and are exposed to substance use, mental illness and criminal justice involvement by their families and household members. As such, mental health professionals should view these co-occurring disorders and other negative life experiences as potential indicators of FASD, necessitating a need for further assessment and evaluation.

Memory

One of the most devastating cognitive deficits of FASD is short- and long-term memory impairment.

Poor memory: Individuals with FASD typically have problems associated with memory. In some instances, these issues can lead to over- and underendorsement of symptoms, contributing to missed and misdiagnosis. In other instances, these individuals can struggle with retrieving and communicating their memories, contributing to issues such as suggestibility, confabulation, fabricating stories and incorrect storytelling.

Suggestibility: The suggestibility of individuals with FASD can be detrimental in at least two ways. First, these individuals may be manipulated into participating in criminal activity by peers. Second, these individuals may be prone to falsely confessing to criminal activities that they did not commit. As such, mental health professionals must take care to verify the accuracy of statements made by individuals with FASD. Mental health professionals should also take the topic of suggestibility into account when phrasing and asking questions during the initial intake and diagnostic assessment process.

Confabulation: FASD and other disorders characterized by memory deficits often co-occur with confabulation issues. Confabulation occurs when new memories are created by filling gaps in recall with one’s real memories, imagination or environmental cues. Incidents of confabulation may occur spontaneously or be prompted. For example, confabulation is particularly likely in situations in which professionals ask leading questions or pressure the interviewee. As such, confabulation can contribute to inaccurate self-reports by the client, resulting in possible misdiagnosis and the development of an ineffective treatment plan.

Interacting with clients

The pervasive symptoms of FASD have important implications for how mental health professionals should interact with clients who may have these disorders.

Importance of simplicity: Individuals with FASD tend to perform better when tackling one task at a time. This is especially true of tasks that do not involve reliance on previous experience to complete. Multistep and complex questioning can result in individuals with FASD shutting down emotionally or responding with factually incorrect or incomplete responses. Mental health professionals should take this into account when screening, assessing and developing treatment plans for this population.

Superficial talkativeness: The propensity for individuals diagnosed with FASD to be charming and talkative may lead mental health professionals to overestimate their level of competence and comprehension of treatment goals. It is important for clinicians to have these individuals demonstrate understanding and knowledge of the question being asked by explaining it back to the professional in their own words. Overuse of yes-or-no questioning can also mask the individual’s true level of impairment.

Misinterpretation of callousness: In some cases, behaviors resulting from FASD symptoms might be mistaken as a choice rather than as a result of the disorders. The social and cognitive deficits of individuals with FASD can contribute to problematic behaviors being misinterpreted as premeditated or manipulative. In fact, many of the behaviors exhibited by individuals with FASD are the direct result of deficits caused by prenatal alcohol exposure.

Screening and assessment

The combination of nuanced symptomatology and diagnostic comorbidity makes the screening and diagnosis process for FASD difficult.

Diagnostic terminology: FASD is an all-encompassing term that includes fetal alcohol syndrome, partial fetal alcohol syndrome, alcohol-related neurodevelopmental disorder and alcohol-related birth defects. In the fifth edition of the Diagnostic and Statistical Manual of Mental Health Disorders (DSM), neurodevelopmental disorder-associated with prenatal alcohol exposure has been added as a condition for further study. This is the first appearance of FASD-related symptoms in the DSM, which means mental health professionals can now diagnose prenatal alcohol exposure.

Missed and misdiagnosis: Missed and misdiagnoses of FASD may explain, at least in part, the limited awareness of the disorders among medical and mental health professionals. A lack of systematic education and training on FASD contributes to this situation. As a result, many children, youth and adults go unidentified and are subsequently unable to take advantage of advanced medical and psychological treatment and services that could render a better quality of life.

Detection difficulties: Another factor that likely contributes to the missed and misdiagnoses of FASD is the fact that these disorders are difficult to identify. Why is that? Visible indicators such as morphological signs are not always present, whereas cognitive deficits are difficult to detect using standardized intelligence measures. This is problematic because individuals with FASD who present with no outward signs of facial feature abnormalities can still possess severe neurobehavioral deficits. In fact, diagnosis of prenatal alcohol exposure becomes increasingly difficult as children grow into adolescence and adulthood. Specifically, many of the physical features of prenatal alcohol exposure fade as children grow physically. Furthermore, the availability of birth mothers and records decrease with time. As a result, many professionals and researchers have called FASD a “hidden disability.”

Importance of identification: Assessment and identification of FASD are essential because the likelihood of impairment related to alcohol exposure increases significantly with each subsequent pregnancy. Identification of these disorders in a first pregnancy provides a viable point of intervention to help prevent alcohol use in future pregnancies.

Treatment

Even in cases in which the individual has been accurately diagnosed with FASD, treatment can be challenging.

Problems with cognitive-based treatments: Individuals with FASD have cognitive (e.g., memory, understanding cause-and-effect), social (e.g., comprehending social cues) and adaptive (e.g., problem-solving ability, generalizing skills) deficits that complicate their participation in cognitive-based treatment. Likewise, insight-based therapy approaches are not encouraged with this population. Therapeutic approaches that incorporate modeling, coaching, teaching and skill building may be most effective with these individuals.

Problems with treatment adherence: Individuals with FASD may benefit more from treatment in structured residential facilities than in outpatient facilities because of the cognitive deficits associated with FASD. Should an outpatient program be the only option, odds of treatment success may be improved by maximizing program structure and tailoring treatment plans to the individual.

Conclusion

The disorders under the FASD umbrella are complex and lifelong. They are characterized by an array of adaptive, behavioral, emotional, executive, physical and social impairments. Considering the prevalence rates of FASD in the United States, it is highly likely that mental health professionals will come into frequent contact with individuals impacted by these disorders. Unfortunately, these disorders often go unrecognized and undiagnosed by many mental health professionals.

Other than simply improving identification of individuals with FASD, another essential step for mental health professionals is to better understand the various challenges and deficits faced by this population on a daily basis. To combat the status quo, mental health professionals are encouraged to seek training on this complex topic and consult with FASD experts when necessary. Taking this path forward will minimize the likelihood of negative short- and long-term outcomes for this population.

 

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Jerrod Brown is the treatment director for Pathways Counseling Center Inc., which provides programs and services benefiting individuals affected by mental illness and addictions. He is also the founder and CEO of the American Institute for the Advancement of Forensic Studies and the editor-in-chief of Forensic Scholars Today. He holds graduate certificates in autism spectrum disorder, other health disabilities and traumatic brain injuries, and is certified as a fetal alcohol spectrum disorders trainer. Contact him at Jerrod01234Brown@live.com.

 

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Counseling Today reviews unsolicited articles written by American Counseling Association members. To access writing guidelines and tips for having your article accepted for publication, go to ct.counseling.org/feedback.

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.