Monthly Archives: January 2015

Case study: The critical need to conduct thorough child assessments

By Gregory K. Moffatt January 29, 2015

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

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

The case

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

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

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

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

But things are not always what they seem.

The assessment

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

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

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

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

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

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

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

Interviews and supporting information:

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

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

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

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

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

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

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

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

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

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

Conclusions

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

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

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

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

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

Follow-up

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

This case presents four very important lessons for counselors:

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

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

3) Be tentative in your conclusions.

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

****

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

Unprepared, undecided and unfulfilled

By Adriana V. Cornell January 28, 2015

A client said to me: “I wish someone would just fill in all the answers.”
Caroline is a bright, motivated and seemingly confident college senior, yet she is terrified of graduation and bewildered in the face of her future. She wants “variety” and options, but she does not want to choose one. She wants a “gratifying and engaging” career, but she does not want responsibility or leadership. She wants a higher degree, but she does not want to spend more time in school.

The flood of graduation and the “real world” is slowly but ruthlessly rising, and Caroline and her peers find themselves neck-deep. Predictability and familiarity have never been so simultaneously precious and deficient. Gone are the days of acceptable denial and excusable procrastination: In roughly three months, college seniors will need to make a decision.

For many of these students, determining the next step will be the biggest and most weighted decision of their lives. They must negotiate not only practical necessities such as housing and a salary but also a personal resolution. Being a student is both an occupation and an identity; transitioning from college to career demands a resignation of the role college seniors know and do best. They have mastered the duties of a student, navigated the nuances of the educational system and understood what to expect and how to succeed within it. As students, they are in control.

Paul Sites, author of Control: The Basis of Social Order (1973), identified eight basic human needs: consistency of response, stimulation, security, recognition, justice, meaning, rationality and control. If these needs are not met, Sites claimed, one cannot exhibit “normal” or nondeviant individual behavior. School, it seems, is the model of this theory. To facilitate optimal learning, creativity and intellectual development, college campuses are designed to meet all of Sites’ fundamental needs.

Grading satisfies justice, recognition and consistency of response. When students complete an assignment, they receive a grade, representing (high or low) achievement. Presumably, professors and other faculty allow students equal opportunity to succeed by providing clear instructions (a rubric) and evaluating the student without bias or comparative measures. Fair and reliable feedback is not only a norm on college campuses but also an enforced requirement.

Students generally feel valued and safe in college. Admissions tours boast of high security on campus, emphasizing the emergency phones sprinkled throughout, 24/7 campus police patrol, convenient transportation and campus alerts sent via text and email. Last spring, University of Pennsylvania President Amy Gutmann responded to an alarming number of student deaths by suicide by forming a task force and informing students that “now is the time to review our work and to ensure that we have in place the best practices in outreach, education, intervention and treatment.” In college, students’ security and safety are the school’s priorities.

But college is perhaps most extraordinary for its pure mission to educate and stimulate. Learning is the primary occupation of students, and through learning, students find meaning and inspiration. Students are in an environment that encourages only growth. The sole purpose of that environment is helping students succeed.

Graduating from college means the loss of a comfortable identity and introduction to a host of empty needs. Syllabi, protection and unconditional (free) support are no longer available. In the workplace, recent college graduates expect recognition and compensation that may not arrive. They expect to be motivated and gratified in an entry-level position. And they expect their co-workers to look after them like their classmates and professors did. Although these employed graduates are left deflated with disappointment, their unemployed classmates are left inflated with anxiety.

In the weeks and months preceding graduation, college seniors anticipate with increasing urgency the imminent loss of resources. Some students begin to feel lonely, abandoned and unable to progress independently. These students typically feel unprepared to face adulthood and career. Others, like Caroline, are undecided. They feel overburdened by the responsibility of making a choice and instead choose nothing. Still others find vulnerability and exploration so threatening that they remain steadfast in their long-standing habits and routines. These students are often guided by their parents’ goals and are ultimately unfulfilled when they find their own wants, needs and identities unexplored and unexpressed.

How can counselors help?

Given the typically last-minute nature of these students’ concerns, counseling interventions should be purposeful and productive. Regardless of the duration of the therapeutic relationship, counselors must be considerate of the treatment deadline: graduation. Fortunately, the college-to-career transition is foreseeable and has precedent. No student is surprised by the end of his or her educational career or unaware of the general expectations that follow. Challenges arise when students interpret or react to these expectations in an irrational or maladaptive manner.

An important distinction should be made at this point: Mental health counselors are neither trained for nor responsible for securing a position of employment for students. Résumé building, networking, job searching and other related logistics fall more within the duties of the career counselor or campus career services. In my view, a mental health counselor’s role is to ready students emotionally and mentally so that they may perform at their best in their next pursuit.

Counseling the unprepared student

In my experience, normalizing fears of the undetermined future is the first step toward helping the student who feels unprepared for graduation. Though basic, this intervention can be powerful for students who reach that much-anticipated “finish line” only to feel disoriented, incomplete and submerged in unfamiliar demands. Celebration and congratulations are flung at them, while they want nothing more than to turn back time. Often, students find themselves in this category due in part to the regular yet empty votes of support and confidence they receive. Throughout the course of their youth, they have been told — and therefore believe — that they have ability, options and, best of all, time. But the rosy fog of encouragement is accompanied by far too few truths.

Typically, students in this category were rarely challenged to follow a course of practicality, and no one ever earnestly asked them what they planned to do after senior year. Although these dreamers fuel the very purpose of education — learning for the love of learning — they find themselves at a startling awakening come graduation. The chilling truths that ability may not be enough, options may not be plentiful and time is not endless are crushing. As counselors, we must first meet these students there, in that emotion. Joining the client is essential to developing a strong therapeutic rapport efficiently, and this is especially critical if time is limited.

Next, a counselor might explore and emphasize the student’s support system. Often, unprepared students feel as though they must approach the real world on their own. Many imagine that immediately following graduation, they no longer qualify as students and, thus, may no longer enjoy the resources a college campus provides. Helping students understand the possibilities and benefits of ongoing relationships with professors, classmates and coaches and how to establish those connections even at the end of senior spring can allow for greater confidence, comfort and a sense of control. Scheduling as few as one meeting with an adviser or professor to discuss career goals can set a platform for regular updates, communication and advice after graduation.

In this context, unprepared students are often good students. Lack of preparation for graduation does not always imply a lack of motivation. Rather, these students are typically unprepared because they are more invested in their education than in their careers. But realizing that this focus, although lauded in college, will be obsolete in a matter of months is disheartening. Counselors might utilize strengths-based counseling and positive psychology to help these students recall their skills and understand how to apply these skills to the professional domain. For example, a student who writes for the school newspaper might emphasize writing skills, an ability to meet deadlines and word limits, community outreach opportunities, creativity and team-oriented skills. By drawing a connection between education and career, counselors might empower these students to embrace life after college as an opportunity rather than as an end to self-directed possibility.

Counseling the undecided student

Whereas the unprepared student is fearful, the undecided student is apathetic. For these students, success is more of a societal guideline than a personal passion or drive. Caroline, for example, hopes to proceed to a doctoral degree for the associated prestige it offers rather than out of a genuine personal interest or purpose. When asked the “miracle question” of her ideal present or future scenario, Caroline replied flatly: “I don’t know.” Students such as Caroline typically seek counseling in hopes that “someone will just fill in all the answers” for them.

Several studies have found that choice leads to greater satisfaction and sense of control. Even the appearance of choice, regardless of the desirability or authenticity of each option, can create increased self-efficacy and superior performance. With this theory in mind, it seems counselors would most effectively help graduating students by presenting them with options (false or genuine): get a job, continue on to graduate school, take a year off, volunteer — or even do nothing at all.

Not only are these “options” vague or unrealistic for many college seniors, but they are also unhelpful. Although choice may offer control and power, too many choices produce confusion and dissatisfaction. Research conducted by Sheena Iyengar in 2011 shows that presenting consumers with multiple variations of a single product (in her study, different flavors of jam) attracts more attention but results in fewer purchases.

The miracle question is futile for undecided students because they see too many choices and “buy” none. For students to understand the differences between choices, they have to be able to understand the consequences associated with each one. Counselors may illuminate these consequences by asking students more specific questions, particularly regarding motivation and everyday realities. For example, a counselor might refer to John Holland’s hexagonal Self-Directed Search model to prompt questions such as whether a student is more comfortable working alone or in groups, with routine or spontaneously, and with his or her mind or hands. Pointed questions may help to eliminate unlikely or distracting options, force the student to think beyond external factors such as salary, prestige and location, and consider internal factors such as gratification, generativity and pride.

Counseling the unfulfilled student

Whereas the undecided student is apathetic, the unfulfilled student is baffled. The unfulfilled student — or, more likely, the student’s parents — declares an ultimate professional goal and explores few alternatives thereafter. The goal often provides the student a direct course to follow and a set of boundaries to stay within. While the student’s peers may have struggled to define their paths during adolescence and early college, the unfulfilled student seems to have found comfort in the step-by-step requirements of an esteemed career. Therefore, it is plausible that, over time, the career comes to represent a majority of the student’s identity. To refuse or abandon that career would be a betrayal of the student’s sense of self.

Although this student may not present with or even report career-related issues, symptoms of anxiety and stress often exist as graduation nears. After years of determination, this student may arrive in session on the eve of senior spring wondering if she or he made the right decision. With constant focus on the ultimate goal and the future, this student largely ignored the process and the present moment. These students may feel that although they have achieved their goal, they have learned very little about themselves and their environment. Stress and anxiety result when this realization occurs.

Research conducted by Nathan J. White and Terence J. G. Tracey in 2011 suggests that students who score higher on self-awareness and authenticity measures are more decisive about career and less likely to be fearful and anxious or to have difficulty believing in their problem-solving abilities. To orient unfulfilled students to their extracurricular identities and to develop their self-awareness, counselors might begin by facilitating exploration around fundamental identity ingredients: likes and dislikes, various roles played, strengths and weaknesses, and accomplishments, failures and goals (for example, starting a family). Next, counselors might focus on the student’s relationships and how she or he exists among others. Examining healthy and unhealthy, positive and negative relationships — particularly with parents in this case — may inform the old patterns and inspire new dynamics in the future.

Conclusion

One important commonality exists among the unprepared, undecided and unfulfilled student alike: All feel that in making a career decision, they must mourn the loss of potential selves. Since elementary school, possibility seemed endless. Parents and teachers promised that they could be anything they wanted to be. But suddenly the music stops, and everyone wants an answer to the dreaded question: What are you going to do now? Being captain of the soccer team, president of the arts and crafts club or editor of the school newspaper seems to pale next to the blank line where a shining career is meant to be — the career that one supposedly spent all this time working toward.

As counselors, we must help students transform their nostalgia for yesterday into enthusiasm for tomorrow. Choosing a career is not a single event but rather an ongoing, lifelong process. Encourage students to see not an end to but a beginning of possibility, and help them find energy in their new independence. For the first time, their lives are entirely in their control. Emphasize not the burden of choice but the freedom.

****

Adriana V. Cornell earned two master’s degrees from the University of Pennsylvania’s Graduate School of Education and now works as a college counselor for high school students. Through private practice, she assists high school students with each step of the college application process, including self-conceptualization, college list development, essay writing and application completion. She lives in Center City Philadelphia with her husband. To contact her, visit adrianacornell.com.

Letters to the editor: ct@counseling.org

Addressing fear in child victims of sexual abuse

By Jennifer M. Foster January 27, 2015

One of the most widely published statistics on child sexual abuse, from the Centers for Disease Control and Prevention in 2005, asserts that 1 in 4 girls and 1 in 6 boys are sexually abused before the age of 18. Furthermore, research by John Read and colleagues in 2004 estimated that 50 percent of adult women and 28 percent of adult men who seek counseling have a history of being abused sexually as children. These statistics point to the high probability that counselors, regardless of their practice setting, will encounter child victims and adult survivors of child sexual abuse.

Unfortunately, few counselors have received specific training with this population, and many practitioners report that they are not adequately prepared to provide counseling to trauma survivors. Counselors’ lack of readiness to address child sexual abuse has numerous consequences. These include failing to inquire about the client’s abuse history, failing to provide a therapeutic response to the client’s abuse disclosure, shifting focus due to an inability to hear the details of the client’s abuse and making inappropriate referrals. Additionally, counselors who lack training to work with victims of sexual abuse may struggle to understand the world of the victim or may experience their own countertransference. Lack of training may also increase counselors’ risk for burnout and vicarious traumatization.

The experiences of child victims of sexual abuse

Counselors may have a narrow understanding of the experiences of child victims of sexual abuse due to the limited research that has been conducted with these children. Most published studies focus on the retrospective memories of adults, predominately women. To address this gap, in 2011 I conducted the first known study exploring children’s written descriptions of life before, during and after sexual abuse through a qualitative analysis of trauma narratives.

The analysis revealed a meta-theme, which was titled “Fear and Safety.” All 21 children (18 girls and three boys) in the study reported fears, including during the sexual abuse, during their attempts to stop the perpetrator and during the disclosure. Fear and issues of safety were also present in children’s discussions of their life now (for example, in nightmares and flashbacks) and in their thoughts about the future. A follow-up study in 2014 explored 19 boys’ narratives and confirmed the meta-theme of fear and safety.

Child victims of sexual abuse often view the world as unsafe, and they are likely to enter counseling with unresolved fears. They need help from their counselor to learn how to cope with their fears and how to increase their internal and external resources. Additionally, these children need an opportunity to voice their unspeakable experiences. Because fear is a central part of the child victim’s experience, counselors need to be prepared to implement interventions that address past, present and future fears.

Interventions that target fears

Several treatment models, strategies and techniques are effective in addressing children’s fears related to child sexual abuse, including the following interventions.

Trauma-focused cognitive behavior therapy (TF-CBT) is a comprehensive, evidence-based treatment model developed by Judith Cohen, Anthony Mannarino and Esther Deblinger. It was designed to address traumas and crises experienced by children, including child sexual abuse. According to a meta-analysis conducted by Wendy Silverman and colleagues in 2008, TF-CBT was significantly more effective than placebo and other forms of trauma treatment designed for children and adolescents.

Unlike other models, TF-CBT specifically targets trauma-related fears through a variety of interventions. One of these interventions is the trauma narrative, in which child victims describe in their own words their experiences before, during and after sexual abuse. For those interested in learning more about TF-CBT, a manual titled “How to Implement Trauma-Focused Cognitive Behavioral Therapy,” created by the National Child Traumatic Stress Network, is available at nctsnet.org/nctsn_assets/pdfs/TF-CBT_Implementation_Manual.pdf. Additionally, counselors and counselors-in-training can enroll in a free 10-hour training in the model, available at tfcbt.musc.edu/.

The “safe place” technique is an intervention designed to help children cope with their fears. The strategy can be taught and practiced during counseling sessions so that child victims of sexual abuse can implement it outside of counseling when fears arise. Counselors start by providing information to children (and, if possible, their parents/caregivers) about the technique and how it can help combat fears. Counselors then help children create their own imaginary safe place by asking questions that encourage children to vividly describe their special place.

For example, the counselor may say, “Close your eyes and picture a special place where you feel completely safe.” The counselor then follows up by asking questions that capture additional details, such as “What do you see? What do you hear? What do you feel? What are you doing in your safe place?” The counselor records these details and uses them to create a script.

Similar to other guided imagery scripts, the safe place script often begins with asking children to close their eyes and take several slow breaths. Many children enjoy using the safe place script as a closing ritual to their individual sessions. This can be especially helpful when the sessions have focused on processing their traumatic experiences.

The safe place script can also serve as a springboard into an expressive arts intervention in which children have an opportunity to create their safe place in a drawing or painting or with clay. This extension of the technique may help children better picture and describe their special place.

The comfort kit (also referred to as the “feel better bag”) was developed by Liana Lowenstein in 1999. Its original purpose was to help children who engage in nonsuicidal self-injury to learn self-soothing strategies, but the intervention can be tailored to meet the needs of child victims of sexual abuse by providing them with a tactile strategy for coping with fear.

The intervention begins with psychoeducation for the child (and, if possible, the parents/caregivers) about the technique. Counselors then help children brainstorm and create a list of items that bring them comfort and make them feel better. Although the counselor guides the process, it is the children who choose what will go inside their box or bag.

Common items that children include are their safe place script, a blanket, music, a favorite stuffed animal, guided imagery (either written or recorded), a stress ball, a list of relaxation activities, bubbles (for deep breathing exercises), a favorite book, a picture of a caring person or special place, a journal and pen, art supplies and a list of self-affirmations. Children then select a container that can hold the items they have selected. The child can decorate the outside of the container, and directions on how to use the comfort kit can be adhered to the inside of the box.

Lifeline is an experiential exercise, described in the literature by Maggie Schauer and colleagues in 2003, that provides a creative way for children to tell their story. The idea of talking about their experiences may be especially daunting for children who have been sexually abused. This unique approach helps them begin the process of sharing their experiences in the safety of the therapeutic relationship.

The intervention begins with the counselor providing the child with a long rope that is spread out across the room. Part of the rope will be used, while some at the end will remain unused (this represents the future). Counselors explain that the rope is a timeline of the child’s life and experiences, both good and bad. Some children may benefit from having numbers written on paper and distributed along the line to represent their various ages. The child is then asked to select two types of objects to mark his or her experiences. One of the objects is used to represent positive experiences, whereas the other object represents negative experiences. For example, flowers could mark positive experiences and stones negative experiences.

As children place the objects along their lifelines, they name their experiences. To specifically illuminate children’s fears, the counselor can ask them to mark situations in which they felt fear. Present fears can also be explored. Once children are done marking significant life events and experiences, they can process the experience with the counselor. For older children, the unused part of the rope (the future) can be explored through questions such as: What positive events do you hope to see in your future? What fears do you have about the future?

To preserve the experience, a photograph can be taken of the lifeline. Children can also be given the opportunity to draw or paint their lifelines. This allows the counselor and child to refer back to the lifeline throughout counseling. This may be especially beneficial when past, present and future fears related to child sexual abuse are explored.

Bibliotherapy is an intervention that has a long history of use with children for a wide range of presenting concerns. It is especially relevant for children who have experienced sexual abuse. Children’s books about sexual abuse can introduce child victims to others who have endured similar experiences, which may lead to decreased feelings of isolation and normalize their trauma-related symptoms. Furthermore, books about abuse can provide comfort, teach important lessons (including that the abuse was not the child’s fault) and offer suggestions for coping. Additionally, some books assist child victims in recognizing their internal strength and identifying safe people who can provide them with support.

Because fear is a predominant issue for child victims of sexual abuse, stories that specifically address feeling afraid may be helpful. Once Upon a Time …Therapeutic Stories That Teach & Heal, written by Nancy Davis, provides counselors with several stories designed specifically for children who feel afraid. A Terrible Thing Happened, by Margaret Holmes, a story for children who have witnessed violence or trauma, is another resource for counselors who are addressing fear and its related symptoms with child victims of sexual abuse. The book is written in vague language so that children who have experienced a wide range of traumatic experiences, including sexual abuse, are able to relate with the main character. The Secret: Art & Healing From Sexual Abuse by Francie Lyshak-Stelzer is another book that would be appropriate to help older adolescents explore their memories and current feelings about their sexual abuse. The artwork painted by the author is powerful, and it succeeds in capturing the numerous feelings, including fear, related to abuse experiences.

Summary

Understanding the experiences of child victims of sexual abuse, specifically their fears and concerns about safety, is an important factor in providing effective treatment. The interventions described in this article provide counselors with strategies to help children express and process their fears in the safety of the therapeutic relationship.

TF-CBT provides an evidence-based approach that targets fears and reduces trauma-related symptoms. The trauma narrative, which is a component of TF-CBT, and the lifeline intervention both provide a way for children to share their stories and voice their trauma-related fears. The comfort kit and safe place script equip children with coping strategies that can be used both during counseling sessions and outside of session. Stories about sexual abuse — especially those that address fear, provide education, reduce isolation and give children further opportunity to explore their personal experiences — are also helpful.

Together, these interventions provide counselors with tools that can help facilitate the healing journey for child victims of sexual abuse.

****

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

Jennifer M. .Foster is an assistant professor of counselor education and counseling psychology at Western Michigan University (WMU). Before joining WMU, Foster worked as a licensed mental health counselor and professional school counselor in Florida. She received her doctorate in counselor education from the University of Central Florida (UCF), where her dissertation, “An Analysis of Trauma Narratives: Perceptions of Children on the Experience of Sexual Abuse,” earned the UCF College of Education Outstanding Dissertation Award. Contact her at jennifer.foster@wmich.edu.

Letters to the editor: ct@counseling.org

*****

Partners in transition

By Stacy Notaras Murphy January 26, 2015

Robyn Chauvin was happily married in the early 1990s. Having spent time in counseling, she had given up drugs and alcohol, was studying to be a music therapist and was working with patients in a psychiatric hospital. But she knew there was one more change she needed to make. “I got very clear that I was not going to pretend to be male anymore,” Chauvin says.

Born looking like a male, Chauvin had lived her life as a man, fell in love and married a woman — but she knew something was wrong. “The one unhappy thing was my gender identity,” Chauvin says. “I grew up in New Orleans, and my idea of male-to-female transsexuals was strippers and hookers. That was what I thought it would have to be. I never imagined it was a possibility for me, and then I got to a point where it felt like an imperative.”

Chauvin describes going through years of deep self-hatred and low self-esteem, with associated depression and substance abuse, before deciding she could no longer pretend to be someone she was not. But deciding to transition to female also would require enormous sacrifices, including a divorce, the concern of possibly resigning her position at the psychiatric hospital and securing significant financial arrangements to pay for her eventual surgery. After going public with her decision, Chauvin found herself welcomed and accepted by the hospital staff and eventually went on to study counseling at Naropa University in Boulder, Colorado. Today, she is a licensed professional counselor (LPC) and music therapist in private practice with offices in Boulder and Denver. She sees adult clients who are dealing with what she describes as “garden variety neuroses,” including gender identity and divorce. “Not to sound too existential, but I think everybody is dealing with gender identity issues,” Chauvin says. “The idea of a gender identity is false.”

Many in the counseling profession are exploring Chauvin’s assertion. The Association for Lesbian, Gay, Bisexual and Transgender Issues in Counseling (ALGBTIC), a division of the American Counseling Association, approved competencies for counseling transgender clients in 2009. The competencies emphasize a wellness-, resilience- and strength-based approach to working with transgender clients, while also acknowledging the multiple oppressions experienced by many in this population.

An April 2011 research brief published by the Williams Institute on Sexual Orientation and Gender Identity Law and Public Policy at the UCLA School of Law said an estimated 3.5 percent of U.S. adults identify as lesbian, gay or bisexual, whereas an estimated 0.3 percent of U.S. adults — or about 700,000 people — are transgender. Meanwhile, a February 2011 study by the National Center for Transgender Equality and the National Gay and Lesbian Task Force (NCTE/NGLTF), titled “Injustice at Every Turn,” revealed that trans people face pervasive discrimination and report staggering rates of attempted suicide.

These findings suggest that you are quite likely to meet a transgender person in your lifetime, and if they turn up in your counseling office, they are likely to have experienced significant ostracism and pain. The good news is that healing can start within the therapeutic alliance. But counselors must be aware of the uncommon factors that might affect these clients, as well as the ways they experience common mental health issues, just like any other client.

Thomas Coughlin, an LPC and ACA member at Whitman-Walker Health (formerly Whitman-Walker Clinic) in Washington, D.C., explains this further. “The needs of this community range from the very basic — i.e., adequate and safe shelter, food, personal safety and protection against discrimination and violence, sometimes from the very agencies in place to protect us — to gender consolidation, navigating romantic relationships and/or ‘coming out’ concerns.”

Pointing to the recent NCTE/NGLTF report, Coughlin notes that individuals in this community often experience “cumulative discrimination” in which they are personally affected by at least three events rooted in bias and discrimination. “It is clear to see how one’s mental health may be impacted,” he adds.

Heather L. Chamberlain agrees. A licensed mental health counselor and self-described “gender specialist” in private practice in Seattle, she applies narrative and feminist theory to her work with transgender clients. “Anyone who is transitioning their gender identity is necessarily involved in rewriting their story and evaluating the impact of systemic obstacles on their past, present and future development,” she explains, noting that she has focused her education and training on gender issues from the outset.

Chamberlain has found that these clients initially present to counseling with marked depression and anxiety. “It is a terrifying prospect to disclose the self-discovery that one’s anatomy and inner experience do not align,” she says. “People fear rejection, loss of employment [and] loss of family, friends and intimate relationships. Initial goals for treatment often include support in coming out, strategizing about how to manage the obstacles and challenges they anticipate in their transition experience and mitigating depressive and anxiety-related symptoms.”

“Often, there are issues surrounding low self-esteem, as many people have spent years living with a gender presentation that they know to be wrong for them and have developed significant self-loathing as a result,” Chamberlain continues. “People who are further along in their transition sometimes have trauma issues to process, perhaps as a result of hate crimes, rejection from family or termination of employment. The risk of suicide for these clients cannot be overstated. The challenges they face are immense and, sometimes, quite overwhelming.”

Chamberlain cautions that one challenge in working with the transgender population comes in the form of witnessing the extreme injustice and marginalization these clients are forced to endure. However, she notes that the work is highly gratifying as well. “I have yet to work with a transgender or gender-variant client who is not intelligent, insightful, creative and incredibly tenacious in one way or another,” she says. “There aren’t words to describe how incredible it is to witness the transformation of a person who comes to you sad, fearful and overwhelmed into a confident, beautiful, successful human being whose outer self aligns with their inner experience.”

Thomas Tsakounis reports a similar experience. An ACA member in private practice, Tsakounis is the executive director of A Quiet Journey Counseling & Associates in Silver Spring, Maryland, where he works with a variety of clients, including lesbian, gay, bisexual and transgender (LGBT) individuals, same-sex couples and families. “Witnessing the shift from nonacceptance to acceptance is one of the most rewarding experiences,” he says. “[Although] oftentimes it doesn’t happen in one session but is more a transition, the work is life altering.”

Tsakounis finds that working through deeply embedded social, cultural and religious views often presents the most daunting challenge. “It is my belief that since many of these views are imparted to youngsters early in life, deviating or breaking free from these belief systems is more challenging as a young adult or adult,” he says. “These deeply steeped views result in challenges in empowering the client to see themselves in a different light.”

Counselor as gatekeeper

Transgender clients present to counseling for a variety of reasons. Counselors may find themselves working with someone who is fully confident at the end of her transition or a person for whom even speaking the word “transgender” may be a new experience.

When a trans person decides to pursue gender reassignment surgery, they are often required to have a mental health evaluation and a letter of support written before receiving hormones or being evaluated for surgery. Coughlin describes this as playing the role of gatekeeper, or being the one with the power to determine if the client gets to live an authentic life.

“When I was doing intakes, I would sometimes be the first person [the client had] ever shared their feelings with. They come in with symptoms of depression or anxiety, and it takes a while to get to the gender stuff,” he says, adding that, as a health center, Whitman-Walker Health addresses the mental health factors alongside the physical health issues that clients are facing.

Coughlin says it is critical that counselors educate themselves on gender identity topics because they are often on the front lines of helping trans people find resources. “We are put in a tremendous position of power to say if [these individuals] can get ‘the surgery’ [gender reassignment surgery],” he says. “They can come in skeptical or unsure. This has been a marginalized community that has dealt with marginalization and discrimination by health care providers, [so they] may come in very distrustful of us.”

Chauvin suggests that counselors attune themselves to situations in which a trans client enters treatment with resentment toward the medical establishment and use that as a way to explore similar resentments and frustrations the client has experienced over a lifetime. She also recommends that counselors be prepared to help these clients if they are facing financial crisis as a result of losing a job or career when they begin to transition. She notes the example of one of her clients who had been running an engineering firm but lost her job and had to become a massage therapist after making the transition to female. But at the center of this process, Chauvin emphasizes, is the same existential question that any other client may face: Who am I in the world?

Rebecca Ouer, a social worker in Dallas, is currently writing a book titled Solution-Focused Brief Therapy With the LGBT Community: Creating Futures Through Hope and Resilience to help educate clinicians. Her philosophy is to make room for the client to fully define himself or herself. “If a client looks to you like a typical male and sounds like what you have always known as a male but wants to be called ‘Nicole’ and referred to by female pronouns, as their therapist, you must get past any and all reservations you have about societal norms and completely respect your client’s definition of themselves. If you cannot do that, you should not be working with this community,” Ouer states. “Do not question their definitions; just respect them and ask them questions about the hopes that they have for their lives.”

Coughlin himself transitioned around 2000, when he says the medical community still struggled with how to help trans people. “The field around transgender people has just totally transformed [since then],” he says. “Way back then, we were still considered to be in this pathology that needs to be corrected. Still [today] people see it as an affliction, a disorder, a tragedy — and it’s not. I come at it from a strengths-based place. Coming into my office is an amazing feat [for these clients]. Trying to become more authentic and more themselves … it’s not a horrible thing. With some family members, this is a courageous thing to go through, so my focus is on how can I help and be of support to you?”

Counselors who are not transgender themselves still can be helpful to clients facing gender identity issues. Tsakounis suggests that counselors consider exploring sensitivity training to help them “separate the myth from the truth.” He adds that coming out often is a long, painful and confusing process. “Seeking support may seem simple and straightforward, but there is a certain degree of courage involved,” he says. “Clients who present to counseling have reached a point where they simply don’t have the answers they seek, and despite their concern about judgment and anonymity, they make the decision to engage professional help.”

For counselors looking for a starting point in their work with these clients, Tsakounis recommends recalling Carl Rogers and the concept of unconditional positive regard. “I am always reminded that whether it is an LGBTQ client or anyone else seeking a counselor/therapist, the bottom line is that when you erase all the labels, what sits before you is a peer — a person who wants to be accepted, listened to and supported. In the end, their sexual identity is a small, very small, part of that human being,” he says. “Offering a safe space where there is no judgment and providing unconditional positive regard [are two] of the most valuable gifts you can give to someone who has known nothing but the contrary their entire life.”

A host of interventions

The diversity of ways a transgender client presents to counseling may be equaled only by the variety of interventions used with this population. Caroline Gibbs, an ACA member, is the founder and director of the Transgender Institute in Kansas City, Missouri, where the model of treatment extends beyond talk therapy. Gibbs explains that the institute’s offerings are multifaceted to truly support transgender people through all phases of their transition. Services include individual and group therapy, one-on-one vocal coaching, mentoring programs, insurance navigation assistance and physician referral, as well as clinical consultation for therapists desiring support as they help transitioning clients. The institute also offers classes on makeup application and hairstyling, Gibbs says, because many trans women are highly interested in learning about these skills and need a safe space to explore them.

“We have a fashion stylist … [and] we have a finishing school for people who want to learn how to sit properly at a table and how to make their way around society. We do vocal feminization, and, of course, we do therapy,” she explains. “99.9 percent of the patients who come here say, ‘I want to blend in. I want to be a woman in this society, and I want to live my life.’ They may choose to be an advocate for their community in the future, but most often they are very sure they just want to blend in.” Gibbs adds that female-to-male transsexual clients may find it easier to blend in faster because testosterone treatments provide physical and vocal changes within three to six months.

Gibbs often starts by inviting clients to write an autobiography, which, she explains, can feel easier than having to vocalize their feelings. “Sometimes people are so anxious they will not talk in therapy,” she says. “They are so afraid to say ‘I’m transsexual,’ so they write out their sessions.”

Gibbs mentions the example of a male-to-female transsexual client who grew up in a household of brothers and with a masculine father who profoundly discouraged her from doing anything feminine. “All she wanted was to play with Barbies,” Gibbs recalls. “So what she did was take her GI Joes and, at 4 or 5 years old, cut out paper dresses and pinned them to the GI Joes. She remembered that when writing the autobiography.”

At the same time, Gibbs says, “I think that the power of a future-focused conversation with this community cannot be overstated. I never spend time talking about my clients’ childhood or delving into the details of their dysphoria unless they ask me to or bring those things up on their own.”

Gibbs says she believes clinicians can sometimes become curious about the wrong things with this community, such as the details of transition that might make clients uncomfortable. “I think that these clients need to be able to be in the driver’s seat of these therapeutic conversations,” she says. “They need to know that they are the empowered ones in our therapy rooms. They are the experts of their lives and of who they are. We are just the experts of the question-asking process to help them get to their preferred future.”

Other clinicians apply their own preferred treatment modalities when working with trans clients. Tsakounis says he frequently uses the Emotional Freedom Technique (EFT) with clients working through feelings of fear, disappointment, guilt, sadness, low self-esteem, anger, anxiety and frustration. A self-administered energy technique that draws on approaches rooted in alternative medicine, EFT helps clients release distress by tapping on various parts of their bodies. “EFT is very effective in helping a client process through feelings more efficiently, while at the same time bringing out some of the more deeply seated feelings,” Tsakounis says. “EFT empowers the client by giving them a simple, easy-to-access tool which they can use at any time.”

Chamberlain, meanwhile, has found success using acceptance and commitment therapy and dialectical behavior therapy techniques to help clients manage anxiety and enhance their coping and containment skills. She also recommends journaling and art therapy techniques to engage the creative mind and bibliotherapy and media therapy (in which counselors use movies and TV clips) to help clients feel less alone.

Coughlin notes that he doesn’t believe therapy is an absolute requirement for trans people. “I think there are people who are high functioning, and this is just a path of self-actualization. They know who they are and have to go this track to be connected to the medical options,” he says. “[For] others, I think really it’s about support in dealing with the other people in their lives, dealing with the coming-out process, societal pressure, loss of family support, being isolated [and] just how to connect. Trans folks are human. You can be trans and be depressed. It’s not necessarily causal.”

How to become a resource

Working with the trans population may demand more than conventional counseling skills. Coughlin, for example, sees much of his calling in this community revolving around advocacy and education for people outside the clinic. He notes that he often does a substantial amount of footwork to help clients find competent providers for mental health and other health care needs.

“It’s more than hanging a shingle and saying, ‘Sure, I’ll work with trans folks.’ We need to refer to people with experience,” he says, adding that word-of-mouth is often how he becomes aware of providers with skills in this area. “I just went to a workshop this morning about transsexuality, and it’s so much more than just ‘read these two books and start taking clients,’” Coughlin says. “You really have to dive in, talk to providers, join a peer group, go to a conference, go to Gay Pride [events and] find out all the resources. You have to have a wealth of information to do this work well.”

Chamberlain agrees and takes issue with how counseling education programs address work with the transgender community, charging that if and when the topic is even discussed, it barely scratches the surface of what is needed. She recommends that counselors attend conferences specific to gender issues, including the Philadelphia Trans-Health Conference and Seattle’s Gender Odyssey conference. She also suggests joining the World Professional Association for Transgender Health and becoming familiar with its most recent standards of care. “Beware of offerings that promise you certification as a ‘gender expert’ in a short amount of time,” she says. “No such certification yet exists. We become gender specialists through years of education, training, reading, involvement in the communities and working with our clients.”

Although Whitman-Walker Health specializes in serving LGBT clients, Coughlin admits that the emphasis often is on the lesbian and gay clients rather than the transgender population. “A transgender person’s experience is going to be very different from a gay man’s experience. It’s important to do the work to see what the community is and who trans people are [to get] a sense of the complexity and diversity in that community, because it’s certainly not ‘one size fits all,’” he explains.

Coughlin’s advice for counselors is to stop thinking about gender the way they have in the past. “It’s a paradigm shift,” he says. “Gender is this fluid thing … more like a soup. … People are everywhere and anywhere in there, and that’s their right as people and human beings. And that’s our role as therapists — to allow them to be seen as they are and to know that when they aren’t able to present as themselves, to meet them where they are.”

****

Contributing writer Stacy Notaras Murphy is a licensed professional counselor and certified Imago relationship therapist practicing in Washington, D.C. To contact her, visit stacymurphyLPC.com.

Letters to the editor: ct@counseling.org

****

Honoring those who will be remembered as true advocates

By Richard Yep January 23, 2015

Richard Yep, ACA CEO

Each year, I have the honor of working closely with the person elected to serve as ACA president. During my tenure with the association, I have shared a special 12 months with a number of these individuals. Each president is hardworking. Each is dedicated to making the counseling profession even better. And each brings his or her enthusiasm and knowledge to the job as ACA president.

During our year together, I get to know these individuals as both the official spokesperson and board chair of ACA. More interesting and meaningful to me is the opportunity to get to know them as people. Typically, before they take office, I have read about these individuals and am familiar with their contributions to the profession. Perhaps I have even interacted with them professionally on various projects. But during their year as president, I get to do a deeper dive that leaves me with a better understanding of their passion, motivation and commitment.

Shortly before the end of 2014, ACA was saddened to learn of the passing of past president Jane Myers (1990-1991). Her scholarly contributions to publications such as the Journal of Counseling & Development were both impactful and voluminous. Her output in terms of journal articles, book chapters and editing projects over the course of more than 30 years place her at the upper echelon of her peers. Jane was particularly committed to the topics of wellness and adult development in the counseling profession, although she had many other areas of interest. With her passing, our counseling constellation is not as bright as when she was in our orbit.

I will also remember Jane for her commitment to advocacy, not only for the profession but also for those who benefit from counseling. Although she was well known within the profession for her writing, her research and her mentoring, I was also fortunate to see her in action on Capitol Hill and with other public policy decision-makers. In my previous life as ACA’s director of government relations, we depended on conveying our message in a clear, concise manner to those outside of the counseling profession. We communicated this message to those whose decisions (and votes) could have a critical impact. Jane didn’t shy away from taking on the role of “advocate in chief” when she served as ACA president.

So, it wasn’t much of a surprise to me when, last summer, nearly 25 years after her ACA presidency, Jane was on the phone with me continuing in her role of advocate. In this case, it was as the executive director of Chi Sigma Iota (CSI), the counseling honor society. Jane saw the importance of having CSI members participating in the ACA Conference and wanted to ensure that we could provide them with the necessary space and support. Her encouragement and advocacy for those at all stages of the profession were still unwavering.

Jane Myers was the kind of president who helped make ACA the voice of professional counseling and the largest organization of its type in the world. You are part of that world. I hope we can all learn from our current colleagues as well as from those who made their mark and are no longer with us. Let’s honor Jane’s incredible contribution to the profession by recommitting ourselves to being even better advocates — both for the profession and for those who benefit from professional counseling.

I look forward to visiting with those of you who will be joining us in Orlando next month for the ACA Conference & Expo (beginning March 11 with preconference learning institutes and concluding March 15) and hearing about your role as advocates.

As always, I also look forward to your comments, questions and thoughts. Feel free to call me at 800.347.6647 ext. 231 or email me at ryep@counseling.org. You can also follow me on Twitter: @Richyep.

Be well.

*****

Editors note: Read more about Jane Myers in the “In Memoriam” piece on page 44 of the February issue of Counseling Today.