Monthly Archives: July 2018

Effective ways to approach sexual assault response

By Hasmik Chakaryan July 10, 2018

The overwhelming number of women who have participated in the #MeToo movement has drawn renewed attention to issues of sexual violence, which remains pervasive in our culture. This newly risen wave has created a refreshed platform for addressing gaps in counselor training for sexual assault response.

Even though statistics from the National Sexual Violence Resource Center show that 1 in 5 women and 1 in 71 men in the U.S. will face sexual assault at some point in their lifetime, very few counseling programs have specific courses designed for training sexual assault response. Instead, counselors learn this “on the job”; we do our best to educate ourselves and to grow based on our experiences.

Those of us who have a special interest in working with this population seek additional training to acquire competence and to keep up with research in the field. Ongoing program evaluation at treatment sites is crucial so that we remain responsible for the outcome of our work and, at the same time, accountable to the public and to the third-party payers. We must constantly ask ourselves: Does what I do make a difference? Is my approach effective?”

The more common experience counselors have working with sexual assault survivors is in the traditional therapy setting, whether one-on-one or in groups, on campuses or within specialized agencies. Working with sexual assault survivors can be long and complicated, but it is often a rewarding journey of healing. Each of us tailors our own theoretical approach and framework to the needs of survivors with the techniques our profession has awarded us. So, we tend to approach sexual assault response from this end, engaging in short- or long-term therapy with survivors at some point on their journeys to heal.

Crisis intervention

An additional way to respond to sexual assault is at its onset, from a crisis intervention perspective. Traditionally, this is where victim advocates come in. Most counselors are not victim advocates, and most victim advocates are not counselors. Likewise, not all sexual assault survivors seek out victim advocate services, especially if they are already in counseling for other things. Regardless, counselors are often on the front lines of sexual assault reports and can be better prepared to handle such situations if they properly equip themselves.

To provide an adequate, timely and holistic response to sexual assault, it is essential that we learn about victim advocacy and incorporate some critical elements of this training into our counseling work when appropriate. Given the lack of specialized preparation during counseling training, I believe that counselors clearly need more tools to help them better respond to sexual assault, and I believe a need exists for an interdisciplinary approach regarding education, prevention and response efforts.

Based on the statistics, at some point during our practice as counselors, we will all encounter a client who reports sexual assault. I have worked in two campus-based counseling centers, and the number of students who reported sexual assault was startlingly high. According to 2016 statistics from the Rape, Abuse & Incest National Network (RAINN), young adults between the ages of 18 and 24 are at an elevated risk of sexual violence. In addition, based on statistics from the Centers for Disease Control and Prevention’s National Intimate Partner and Sexual Violence Survey published in 2011, it is estimated that 1.3 million women were raped in the past 12 months in the U.S. What I have learned over the course of the past 11 years in practice — as well as from my clients, students and colleagues — is that we, as counselors, need stronger training for providing a more timely and appropriate response to sexual assault.

In attempting to provide additional resources for my students who want to specialize in sexual assault response, I have found that the availability of trainings and educational programs varies widely from state to state. Information on these services and resources is scattered. We need to create education, training and workshops for those who want to specialize in this work. Perhaps what is called for is a nationwide network in which training and specialty certifications are streamlined and accessible in every state.

Meanwhile, I have attempted to put together a user-friendly diagram for counselors working with sexual assault survivors. In the remainder of this article, I will present a model that may help to organize sexual assault response into groupings for individuals who want to easily locate the appropriate next steps after a sexual assault or rape report. Allowing the survivor to have a voice and a choice in what comes next should serve as the most significant guiding element for counselors.

 

A chart of required or recommended action steps to take immediately after a report of sexual assault (courtesy of Hasmik Chakaryan).

 

Response to assault based on immediacy

One important recommendation is to always consider how the individual refers to herself (or himself) before using terms such as “victim” or “survivor.” The chart above walks readers through the required or recommended action steps immediately after a sexual assault report.

First, assess for safety. When working with victims of crime, it is critical to always consider their immediate needs first. It would be challenging and potentially damaging to the client to process any emotional responses without first addressing the physical or physiological needs, much like Abraham Maslow’s hierarchy directed.

Second, evaluate psychological needs. What are the individual’s most pressing psychological needs? This is where counselors apply their attending skills and provide the individual with empathy and respect.

From the tens of thousands of unprocessed rape kits (per a 2015 article in USA Today) to recent public rulings reducing sentences for college assaults (CNN, 2016) to new proposed laws that would permit a rapist parental rights (CNN, 2016), it appears that our society sometimes is confused about who the victim is and often participates in victim blaming. This widespread phenomenon often affects the ability of victims to recognize their experiences as assault and themselves as victims. It is imperative that counselors work against these societal/cultural norms by first questioning their own views.

Professionals need to check their assumptions and biases regarding sexual assault and who the victim is prior to sitting down with these individuals face-to-face. Counselors must become outspoken advocates for this population and ensure that the best psychological services are provided for survivors of this crime. This requires us to be nonjudgmental and to assert that a sexual assault is never the survivor’s fault. We should include assurances that the survivor is not responsible for either the crime or for the direct effects of that crime.

Third, lay out legal options. Does the survivor want to report the assault? Counselors do not provide legal counsel, but they do need to be informed about certain key elements when working with survivors who discuss legal actions. Most important, never make these individuals feel pressured to report; always allow them to make their own informed decisions.

If survivors decide that they do want to report the crime, inform them of the following:

  • Pursuing legal action requires collaboration with legal services, local police and forensic services. It is vital to process crime scenes immediately while there is still viable evidence and a better chance of locating witnesses to interview for accurate findings.
  • In some states, individuals can access treatment and counseling free of charge when they report the assault.
  • Reporting the assault can be empowering for some survivors and can help them regain some sense of agency. Reporting does not, however, guarantee that the perpetrator will be prosecuted. It is vital to avoid giving survivors false hope and expectations. In fact, a very small percentage of reported sexual assaults end up with the arrest of the perpetrator. According to a 2016 CNN report, of the nearly 300,000 average annual rape and sexual assault victimizations between 2005 and 2010, only about 12 percent resulted in arrests. Such statistics shouldn’t be shared to discourage individuals from pursuing legal actions. Rather, it is critical to process the expectations of sexual assault survivors in counseling.

Forensic exams

It is important to clarify the role of the forensic examiner (or the sexual assault nurse examiner) to sexual assault survivors. These medical professionals are very different from the nurses one might associate with a hospital emergency room. Instead, they are fulfilling a criminal justice role during the sexual assault exam, which is essentially a procedure to collect evidence. It is also imperative to explain the purpose of this forensic exam, the time sensitivity, the statute of limitations and the costs associated with the exam.

If survivors decide to pursue a forensic exam, notify them that they can terminate the exam at any time and can ask for a victim advocate or anyone else they want to be with them in the room. In most states, survivors of sexual assault incur no cost for the exam. The cost depends on what is included in the exam, what lab work and testing are performed, whether testing and prevention of sexually transmitted diseases are completed and whether any injuries incurred during the assault are treated. It is important to check any laws that may hinder the process in any way so that no unrealistic promises are made to survivors.

Counselors working with sexual assault survivors should know that many states process sexual assault forensic exams and related services under the Violence Against Women Act. One valuable resource for professionals and survivors is the RAINN website (rainn.org/articles/rape-kit), which offers a detailed rundown of what happens during the forensic exam. This information helps individuals grasp the importance of the forensic exam for evidence collection and assists them in making informed decisions. For all these reasons and more, independent advocacy is crucial for sexual assault survivors during the exam and throughout the entire process.

Immediate vs. delayed reporting

Providing survivors with information regarding the pros and cons of immediate versus delayed reporting can help them make educated decisions and aid the reporting process. Most of the information that follows in this section on the important elements of reporting and what reporting entails is based on the work of Andrea Sundberg and Dorene Whitworth at the Nevada Coalition Against Sexual Violence.

When a survivor of sexual assault arrives at the emergency room, the police are notified. Officers will interview the survivor for a thorough account of the assault. This helps them collect all of the crucial details while the person’s memory is fresh, giving them a better chance of collecting evidence to aid the legal process.

Providing a report of the assault to police is not the same thing as pressing charges against the perpetrator. Those are separate processes. It is vital for counselors to talk about this with sexual assault survivors and to prepare them as best they can. Not all police officers are trained to work with sexual assault survivors, and this interview may be triggering for these individuals.

Survivors may also choose to delay the reporting until they feel better prepared to handle it emotionally. The potential consequences of delayed reporting can include additional hurdles for thorough investigation, a lack of witnesses and a fading of the person’s memory regarding details of the assault. Delayed reporting may also affect the perceptions and responses of prosecutors and jurors and influence the prosecutor’s ability to obtain a conviction.

No report to law enforcement

Counselors working with sexual assault survivors may assume that the best direction for survivors to take is to immediately report the crime. There are many reasons why survivors may not want to report to law enforcement, however.

Most individuals hesitate to report immediately when there is fear of further danger to self, family or others. Others hesitate to report because of cultural beliefs or because of financial dependence on the perpetrator. Some individuals fear the investigation might reveal some kind of illegal activity related to underage drinking, prostitution, immigration status or other issues. Other individuals are simply terrified at the prospect of facing their perpetrators.

Some survivors will not report to law enforcement because of a sense of shame or embarrassment or because they worry about being blamed for the assault. There are also survivors who do not want to get their perpetrators in trouble because they are family members or are current or former intimate partners of the survivor. Some individuals may fear retaliation, especially if the perpetrator is their superior, employer or supervisor. If the perpetrator is a popular figure, survivors may fear social condemnation and disbelief if they report. Some survivors may lack trust in, or have had a prior negative experience with, law enforcement or the criminal justice system.

After obtaining 40 hours of intensive training in sexual assault response, I volunteered as a victim advocate, providing resources over a crisis hotline to individuals in central Ohio. Often, I would get calls from women saying they had been sexually assaulted by someone involved in law enforcement or the criminal justice system. These women feared more severe consequences if they chose to report. In some cases, these perpetrators were the survivors’ past or current partners; in other cases, they were not related to the survivor at all. In one particular case, the survivor told me over the phone that she feared going to the emergency room because the same police officer who had sexually assaulted her might respond to the call while he was on duty.

Regardless of whether individuals choose to report an assault, a forensic exam is available to them. The Violence Against Women Reauthorization Act of 2013 made it easier for all survivors to obtain a “Jane Doe rape kit,” through which they are given a code to identify themselves should they choose to report at a later date. Under this regulation, survivors must be offered a forensic exam and reimbursement for the cost of the exam without being required to participate in the criminal justice system or cooperate with law enforcement. This applies to all states in their applications for STOP Violence Against Women Formula Grants. In addition, survivors are not required to use their insurance benefits to pay for the forensic exams, which can offer them extra protection.

When educating sexual assault survivors about all of the possible options, it is critical not to make any promises that cannot subsequently be fulfilled. It is important to first find out how specific jurisdictions work and what procedures they follow. It is also imperative that counselors not pressure a survivor into any of these steps or decisions just because the counselor thinks it might be the best option. These individuals were already stripped of their choice and autonomy when they were coerced into nonconsensual sex, so it is vital that this agency be given back to them as part of the process that follows.

It is also important for counselors to know that sexual assault survivors are not limited to only one type of reporting. Indeed, there are various kinds of reporting, including:

  • No law enforcement involvement
  • Law enforcement involvement, storage only
  • Law enforcement involvement, anonymous/blind report (blind reporting is not the same as a third-party report; blind reporting means that the victim is involved but not identified)

For additional details on each of these options, refer to usmc-mccs.org/articles/restricted-vs-unrestricted-reports-know-your-options/.

Student/supervisee disclosure

When disclosure of a sexual assault is made by a student or supervisee, it is crucial to be trained in your institution’s Title IX regulations and requirements to respond adequately. The response will also depend on whether the individual is considered under the age of consent in your state.

I usually immediately connect students or supervisees with an on-campus victim advocate who then walks them through the entire process. I offer my expertise and answer their questions and concerns to ease some of their fears before referring them. If they request that I make the initial contact with the victim advocate and help facilitate the meeting, I offer to go to the first meeting with them.

The process of disclosing a sexual assault and deciding whether to report it understandably provokes anxiety in survivors. They are dealing with multiple effects that may include physical, psychological, spiritual and other issues. The most important piece for me is to make sure that I am present, available, attentive, caring, empathetic, responsive and nonjudgmental, and that I am able to provide a safe place for the survivor. I recommend that we all frequently assess our assumptions and biases regarding sexual assault and who the victims are because these are the nuances that can erect barriers between us and sexual assault survivors.

For more information about campus sexual assault prevention and services, see the White House Task Force to Protect Students from Sexual Assault 2014 fact sheet at justice.gov/ovw/page/file/910266/download.

Other considerations

Short-term crisis intervention vs. long-term counseling: Short-term services for sexual assault survivors include the initial crisis response and intervention immediately following the assault. Long-term mental health services might include a variety of therapeutic components such as assessments, goal setting, treatment planning and step-by-step work through each mental health concern and progress toward therapeutic goals.

A 2014 White House task force study of a community sample of rape survivors found that survivor outcomes were better in communities that had a greater number of post-assault resources. This also means that survivors report better outcomes when short-term crisis intervention is followed by long-term services such as a combination of individual counseling and group support work. Sometimes, it also may be beneficial to involve the family in the therapeutic process.

Trauma-informed care for treating sexual assault survivors: Trauma-informed care is a service delivery framework that considers the unique needs of trauma survivors by treatment providers. As part of this approach, important questions, such as how survivors should be treated by clinicians and what clinicians should be aware of when they are the first contact for mental health treatment, are addressed. Trauma-informed care simply adds a context of trauma to whatever theoretical approach and techniques clinicians find appropriate to use in their work with sexual assault survivors. It also brings up critical elements of neuroscience as a background to our clients’ trauma experiences.

Culturally competent counseling: Trauma looks different depending on the culture. In some cultures, women are blamed for being sexually assaulted. They are subsequently stigmatized, isolated and labeled as “damaged goods,” often resulting in them remaining alone for the rest of their lives. In other cultures, laws allow perpetrators of sexual assault to walk free while victims are either banned from the community or suffer severe punishments such as hanging or stoning.

To work effectively with sexual assault survivors in either short-term or long-term settings, it is imperative for counselors to possess strong contextual knowledge of the individual’s cultural, religious and ethnic backgrounds. Such knowledge helps us understand intricate nuances regarding the survivor’s self-perception, self-worth and perception of sexual acts, including those that were not consensual. It also allows for a more open conversation in a safe and nonjudgmental environment so that counselors can better guide survivors through their unique circumstance.

It is our ethical responsibility as counselors to continuously seek more education, awareness and self-growth in relation to culturally responsible and evidence-based counseling services.

Sexaual assault response training for counselors who desire to specialize: In most states, various sexual assault response teams carry out victim advocate trainings. These trainings are typically 40-hour, intensive educational experiences that include interdisciplinary input from experts in various specialty areas. Counselors who are not equipped to work with sexual assault survivors can always find a victim advocate to refer to in the area.

For more information on locating victim advocates in your area, see the National Organization for Victim Assistance website at trynova.org/crime-victim/advocacy/list/.

For more information on victim advocate roles and trainings, see the National Center for Victims of Crime website at victimsofcrime.org/help-for-crime-victims/get-help-bulletins-for-crime-victims/what-is-a-victim-advocate-.

For hotlines and other helpful links from the National Center for Victims of Crime, see victimsofcrime.org/help-for-crime-victims/national-hotlines-and-helpful-links.

 

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Hasmik Chakaryan is an assistant professor and director of clinical programs in the Department of Professional Counseling at Webster University. In addition, she is a licensed professional counselor, a clinical supervisor, a victim advocate and a trauma specialist. Her research also focuses on internationalizing the profession of counseling. Contact her at hchakaryan06@webster.edu.

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.

The therapeutic triad of disability

By Susan Stuntzner, Jacquelyn Dalton and Angela MacDonald July 9, 2018

For many counseling professionals, the exploration of forgiveness, self-compassion or resilience can seem daunting, particularly when determining ways to apply these concepts to people with disabilities and their specific needs. When approaching this task, counselors may ask themselves several questions, including: Where do I start? Which concept is most important? Is one of them more relevant for this population? How can I best help people explore one or all of these concepts? Good questions indeed but not always easy ones to answer.

To help counselors understand each of these concepts, the three authors of this article developed a model called the therapeutic triad of disability. The therapeutic triad provides counselors a means with which to consider one or all of these approaches as a gateway to healing and a pathway to hope for clients.

A personal search for therapeutic approaches

Susan Stuntzner’s experience: I am the director of disability services at Southwestern Oregon Community College and a lecturer for the University of Texas Rio Grande Valley. I have lived with a visible disability for more than 30 years.

In the summer of 1985, I broke my back and found myself paralyzed from the waist down. I was life-flighted to Sacred Heart Hospital in Eugene, Oregon, to undergo emergency surgery. Prior to the surgery, the attending physician told me that I would never walk again. Putting his pronouncement aside, I thought to myself, “Hmmm, maybe, maybe not. Time will tell.”

Following surgery, I was in Sacred Heart for two months while I underwent physical therapy and learned to walk with the assistance of below-the-knee ankle-foot orthotics. Over those two months, I had a lot of time to think about my predicament, how the course of my life had changed and the road ahead of me. I remember having an innate sense that my life would never be the same, that I could not go back to my “old life.”

At the same time, I found myself feeling a sense of hope. I was already anticipating that my life would be filled with new adventures, personal growth, challenges and possibilities. I can’t explain why I felt this way, but I distinctly remember seeing myself at a vital fork in the road, and now my life purpose was to take the “left road” instead of the one on the right. Perhaps this was the start of resilience and the very beginning of great things to come.

Over the next several years, I was faced with a number of experiences that I wasn’t prepared for, nor did I understand them at the time. Most of these experiences could be filed under what we know of today as negative societal attitudes toward people with disabilities: inaccurate beliefs, low expectations, bias, discrimination, oppression and a lack of equitable access to the opportunities and resources enjoyed by people without disabilities. This was a time when no one really discussed the experience of disability or the impact of society and barriers on people with disabilities. As a result, the process of figuring out what I was experiencing or what I should do was ambiguous at best.

That may not be easy for some readers to hear, but I share it because all of these experiences set the stage for what was to come. I just didn’t know it yet. It wasn’t until about a decade later, while I was a master’s student in Portland State University’s counseling program, that I formally learned about the realities and impacts of societal attitudes toward people with disabilities, the coping and adaptation issues that people with disabilities often experience and the changes in relationships and expectations that this population frequently faces. It was at this point that my personal experiences finally “had a face.” I could look at my personal experiences and better understand why life was now very different from a societal perspective.

Jacquelyn Dalton’s experience: I am a rehabilitation counseling educator, and I have had my own experience of living with a disability. However, my story is one of progressive hearing loss and the challenges and difficulties that come with that. I grew up in the “hearing world” but became profoundly deaf in my mid to late 20s. When I was in my late 30s, I pursued and received bilateral cochlear implants. Because of these implants, I am able to hear and to re-enter the world of the hearing person. However, this was not the end of my experience with disability.

Throughout this time, I worked hard to figure out where I fit in the world. My situation was one in which I wasn’t accepted by the culturally or functionally Deaf population, nor did I fit neatly into the hearing world. As time passed, I sought out other means of coping and adapting to changes brought on by my hearing or my lack thereof. I too witnessed the face of societal bias, inaccurate perceptions and the overstepping of personal boundaries.

Some of these issues were readily noticeable the moment I acquired a service hearing dog named Ainsley. Although providing a vital service and need, Ainsley suddenly made my hearing loss “visible” to the outsider and onlooker. With this experience came the presence of well-known issues that most people with disabilities encounter: strangers staring or gawking at them, invasive personal questions, unkind remarks and social intimidation tactics. To cope with these unexpected and difficult experiences, I began my own journey of exploration, which led to the discovery of mindfulness, meditation practices and Buddhist teachings.

What is the therapeutic triad?

The therapeutic triad of disability is a model and an approach to counseling that comprises three specific components: forgiveness, self-compassion, and resilience. Those who have embraced it have described it as a lifesaving strategy. People have told us that the therapeutic triad helped them move from a place of despair, darkness, anxiety and uncertainty to one of strength, hope and self-confidence. Through the therapeutic triad, these individuals discovered the power of forgiveness, self-compassion and resilience — and the interconnectedness of each component — on a journey of self-growth and personal healing.

So, how did the therapeutic triad come about? In 2012, Susan was looking for a way to expand the use of forgiveness among people with disabilities. This led her to the exploration of forgiveness as a potential component of resilience. Not seeing a lot available on either component in relation to people with disabilities or as part of an integrated approach, she started to work on it.

One outcome of this exploration and research process led to the development of Susan’s second book, Reflections From the Past: Life Lessons for Better Living. The book looks at a number of specific resilience-based strategies that people can use in everyday life. Each skill is categorized and housed within a specific resilience domain to help readers better understand the connection. Some of the skills presented focus on spiritual practices and forgiveness.

From there, an opportunity presented itself to Susan to explore the applicability of self-compassion to the field of rehabilitation counseling and to the process of counseling people with disabilities. Soon thereafter, she participated in one of Kristin Neff and Christopher Germer’s intensive trainings for individuals wishing to delve deeper into the therapeutic value and vitality of self-compassion. Neff and Germer are co-founders of the Center for Mindful Self-Compassion.

Occurring simultaneously, yet unknowingly, with Susan’s experience, Jacquelyn was undertaking her own personal exploration of mindfulness, meditation, compassion and self-compassion. Her life experiences led her to consider Buddhist practices, with some of her initial work being influenced by scholars such as Sharon Salzberg, Ron Siegel, and Pema Chodron. As part of these studies, she became mindful of the importance of compassion, acceptance and forgiveness in people’s lives. Later, she added to this understanding by familiarizing herself with Neff’s work and attending one of her workshops on self-compassion. Each of these pieces helped Jacquelyn better understand the interconnectedness between mindfulness, compassion, forgiveness and resilience, which she later started to apply to disability, trauma and other life challenges.

Angela MacDonald, a licensed mental health specialist and clinician at Frontier Behavioral Health, journeyed through her own experiences and exposure to forgiveness, self-compassion and resilience as part of her education and counselor training.

Throughout our individualized paths, we started to see the interconnectivity between these three therapeutic skills and approaches and, thus, the therapeutic triad of disability was developed. Each component of the therapeutic triad — forgiveness, self-compassion, resilience — is a portal or gateway to therapeutic healing and serves as a pathway to the other components. This is because people often begin therapeutic work in one area, only to discover that they could benefit from looking at other issues that are better addressed by one of the other two components.

For example, as part of their collaborative resilience intervention research, Angela and Susan have exposed people with various disabilities to a 10-week resilience-based skills intervention, “Stuntzner and Hartley’s Life Enhancement Intervention: Developing Resiliency Skills Following Disability” (developed by Susan in collaboration with Michael Hartley of the University of Arizona). Over the course of 10 weeks and 10 different modules, these individuals learned and applied specific resilience-based skills to their lives. Modules six and seven focused on forgiveness and self-compassion, respectively. While learning about these skills, many individuals became acutely aware of their need to work on forgiveness and self-compassion as key components to their healing, making them willing to explore one or both at a later date.

Angela regularly works with numerous people, individually and in a group context, on resilience and forgiveness. She witnesses people become more open to forgiveness after doing some initial work on resilience or sees people recognize the need for self-compassion after they have started learning how to forgive. It is amazing to watch people grow and draw from all three components as part of the therapeutic experience.

The benefits

People who practice forgiveness, self-compassion or resilience will experience a number of benefits, some of which are unique to that particular component and some of which overlap with the other components. To give counselors an idea of the benefits that these three components offer, let’s first consider some of the similarities.

The therapeutic triad, regardless of where people begin, affords clients the opportunity to increase their self-insight into the thoughts, feelings and choices that they have and make. As a result, clients may come to recognize that they engage in thoughts, feelings and behaviors that are not helping them heal or move forward. When this happens, people can decide what they are going to do instead.

An example of this was evident in the resilience intervention work that Susan and Angela conducted. By the third week of the intervention on resilience-based skills, participants had covered the meaning of resilience, the role of attitudes and beliefs, and the role of locus of control. It was during this time that a group member said, “You know? These exercises are really helping me see how I think and feel. I had no idea that I harbored this much negativity and that I talked to myself this way.” When the group member shared this insight, we asked him to be “kind and accepting” of his personal discovery and to realize that he also now had an opportunity to do something different.

Forgiveness, self-compassion and resilience can be used to help people reduce negative thoughts (e.g., mental rumination, self-judgment, critical thinking) and feelings (e.g., anger, anxiety, depression, hostility), diminish fears and decrease negative psychological reactions to the disability. They can also help people heal emotional hurt, feel less socially isolated and more connected to others, improve social relationships (including the relationship that people have with themselves), improve self-esteem, find hope, develop the ability to sit with their pain, and be kinder and more accepting of themselves.

In addition, each of these components may be a portal to another. For instance, when people work on forgiveness, they often realize they are not self-compassionate; thus, it provides a way to start working to change that. If resilience is the starting place, people often discover an accompanying need to work on forgiveness or self-compassion.

Jacquelyn has made similar observations pertaining to the interconnectedness of these skills in her work with military veterans. One veteran with posttraumatic stress disorder who is recovering from alcoholism told her, “The VA [Department of Veterans Affairs] tells you about resilience, but no one really shows you how to do it. It was not until you gave me information on self-compassion that I started to feel better. It was through this exposure to self-compassion that I then realized that some work on forgiveness was in order. I now see that the more I work on self-compassion, the more forgiveness I am able to experience.”

Overcoming barriers

Counselors working with people on the therapeutic triad have some options in the ways they can explore and address the barriers that people encounter as a part of the triad process. Like the benefits that people encounter, some of the barriers may be similar across the therapeutic components, whereas others will likely differ. Thus, counselors may want to consider which approach is best tailored for each person’s needs and situation.

For instance, some may decide to use an educational or more formalized approach in exploring and discussing potential barriers. Such an approach may be particularly useful in psychoeducational settings or as part of group counseling. Others may decide to use the exploration of barriers as a key feature of preparing clients for work on forgiveness, self-compassion or resilience. Still others might address “barrier identification” work on an individualized level and discuss them as they surface in the counseling relationship.

Susan and Angela, as part of their individualized and collaborative work, constantly revisit which approach works best for the situation, the person and the therapeutic context. In their collaborative group work, they have used a combined educational and self-assessment identification process. In the group setting, they typically educate group members about some of the barriers that people experience when working on a skill such as forgiveness, self-compassion or resilience. This is followed by the opportunity for group members to self-assess and explore their own personal barriers.

Susan and Angela have found that this combined educational and self-assessment identification process helps people realize that it is OK to encounter some kind of barrier. People learn that barriers are part of the human condition and their presence does not warrant adding additional layers of shame, guilt or self-criticism to a person’s self-concept. In the end, people are empowered to make a choice to do something different. To help counselors better understand the plethora of barriers people may experience as part of the therapeutic triad, we will provide some examples.

When exploring forgiveness, it is often difficult for people to ask for help in learning to forgive. Forgiveness is difficult because it is a personal process in which people are asked to face and address deep hurt and painful experiences. This process is compounded by the fact that some people believe that forgiveness is for the “weak” or that it is too hard to achieve. Others mistakenly believe that forgiveness is only for people who are religious or spiritual. Still others find it hard to forgive because they cannot “let go” of the pain or because they harbor feelings of blame toward themselves, others or God.

People commonly experience barriers in the cultivation of self-compassion when they hold on to negative thoughts and feelings, have difficulty letting go of the past or engage in critical or judgmental thinking about themselves. Some people cannot find their way to a self-compassionate way of life because they spend most of their time thinking only of themselves, feeling sorry for themselves or believing they do not deserve self-compassion.

Because of the nature of resilience and the reasons that people find themselves attracted to it, the barriers encountered may be different than those encountered for forgiveness or self-compassion. Part of this is because people tend to work on resilience following a life-changing or traumatic event, not when life is going well. Some common barriers include:

  • Believing a situation or event is unfair and that the choices you make will not result in a difference
  • Blaming other people for your situation
  • Feeling that you do not deserve what is happening to you, especially when you have done all of the “right” things
  • Continually asking “why” something is happening rather than working on potential solutions

Therapeutic strategies for skill cultivation

Counseling professionals interested in pursuing forgiveness, self-compassion or resilience work with clients are encouraged to consider a few initial questions, followed by employing some strategies as part of the therapeutic relationship.

  • Which of these — forgiveness, self-compassion or resilience — is most relevant to the person’s situation?
  • How do these skills relate to the person’s experience of living with a disability and its associated life changes?
  • Does the person seem more receptive to one of these approaches than the others?
  • What beliefs or practices does the person have or follow that can aid in this exploration?
  • In the given situation, which of the skills is most important for positive coping and adaptation to disability?
  • How can I help the person start on one area and use it as a portal for healing in another?
  • Do I cover each of these skills separately or as an integrated part of an intervention?

Professionals who are counseling clients with disabilities can choose from a number of strategies, especially given the multiple paths for cultivating forgiveness, self-compassion and resilience. The key is to find those that work for the person and that are relevant to the individual’s experiences. As previously mentioned, each of these skills often opens the door to another, so there is no one right place to begin.

Having said that, Susan and Angela have found that it often helps people to consider forgiveness and self-compassion after doing some initial work on resilience. Part of this may be because many of those with whom they have worked were exposed to forgiveness and self-compassion while learning resilience-based skills. As part of the process to build resilience, people often realized their need to work on the other two components.

Counselors may elect to work with people individually, in groups or in a way that accesses some of both. Counselors can approach the therapeutic triad from a psychoeducational approach, an intensive therapeutic approach or a specific counselor theory. They can also infuse techniques such as educational topic sessions, self-assessments/insight-driven exercises, bibliotherapy, specific exercises geared toward skill cultivation, interventions, meditation and spiritual practices, writing and reflection exercises, and therapeutic homework.

 

 

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To learn more, visit The Thoughtful Counselor podcast archives (thethoughtfulcounselor.com/all-episodes/) for a two-part conversation that Mike Shook facilitated with Susan Stuntzner and Angela MacDonald about the intersections of disability and forgiveness, self-compassion and resilience (episode dates: Feb. 17 and Feb. 21).

 

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

Susan Stuntzner is the director of disability services at Southwestern Oregon Community College and a lecturer for the University of Texas Rio Grande Valley. She is a licensed professional counselor (LPC), licensed mental health practitioner, certified rehabilitation counselor (CRC), national certified counselor (NCC) and board certified telemental health provider. Contact her at susan.stuntzner@socc.edu.

Jacquelyn Dalton is an assistant professor in the Texas Tech University Health Sciences Center within the Department of Clinical Counseling and Mental Health. She is a CRC and an NCC.

Angela MacDonald is a licensed mental health specialist and clinician at Frontier Behavioral Health. She is an LPC, CRC and NCC.

 

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.

 

Superheroes and play therapy: The perfect imaginary combination

By Jetaun Bailey and Tonya Davis

Superheroes have a profound influence on American culture. Recently, Marvel Comics’ Black Panther came to life on the movie screen. It appears the movie had a twofold impact.

First, it brought heroic life to a seemingly little-known character. Second, unlike most other big-screen superhero movies, Black Panther placed value on social consciousness, awareness, community, family and pride. It broke boundaries that went beyond simply box-office sales, introducing a male of presumably African descent as the superhero. During the movie’s opening weekend, many news outlets showed young African American children wearing their dashikis as a symbol of pride in the African ancestry depicted in the movie.

As a culture, we hold our superheroes in high esteem, even if they are fictional characters. Thanks to Black Panther, many African American boys can identify with a superhero for the first time. This experience has likely heightened the imaginations of many African American boys as they imitate characters from Black Panther in their play.

Escaping to the imaginary worlds of our superheroes seemingly has therapeutic powers. Author and blogger Remez Sasson describes imagination as the mental ability to formulate an image that is not tangible through our five senses. For young children, an even deeper escape possibly occurs when watching these types of movies. The imagination is a powerful tool for children, as reported by Patti Teel in Pathways to Family Wellness magazine. When children imagine, they can visualize their heart’s desire, thus welcoming it into their reality.

 

Reaching beyond traditional play therapy

The therapeutic power of imagination is also evident in various therapy practices, specifically play therapy. According to “Helping a Child Through Play Therapy” by Jane Framingham, adults mistakenly think that child’s play is solely for fun and games or to occupy time. Unbeknownst to these adults, through creative and imaginative play, children are developing cognitively and emotionally while improving their self-worth, positive self-image, and communication and coping skills. For those reasons, play can be therapeutic in helping children overcome challenges that might inhibit developmental growth.

To tap into children’s imaginations and gain deeper understanding of their problems, play therapists are reaching beyond traditional play therapy tools such as sand trays, crayons, paints, animals, toys and dolls. Technology appears to have revolutionized the art of play therapy, thus making it easily accessible to counselors. This can be especially important for school counselors, who work in settings in which the counseling process is often limited because of the other administrative duties assigned to them.

Technology-based programs such as Marvel’s Superhero Avatar Creator and DC Super Friends Super Hero Creator represent the infusion of electronic media into play therapy. Based on “The iPad Playroom: A Therapeutic Technique” by Marilyn Snow and colleagues, the infusion of technology increases the imagination and creativity of the child by allowing the child to create media, pictures and other artwork while the therapist is present, either in conjunction with or separate from the therapist. For example, many applications are available to aid children in fueling their imaginations to create family dynamics or events through drawing and colors that possibly hold symbolism to their presenting problems. This invites the opportunity for metaphors to help solve real-world problems.

 

An ideal therapeutic method

This method of integrating superheroes through a technology approach in play therapy potentially could be an ideal therapeutic method of working with children, especially African American males, in the school setting. It appears to offer a nonintrusive approach for getting students involved in counseling because it integrates technology and play without asking probing questions.

As former school counselors, we have been disturbed by the alarming rates of African American boys being suspended because of perceived aggressive behaviors. Through our lenses, we have seen many of these students struggling with low-self-esteem or low self-worth. Ironically, sometimes these issues are not apparent through traditional presentations such as withdrawing or isolating.

The adjustment between school and family cultures has proved problematic for African American males regarding understanding their importance and worth. This likely causes tension in the school setting, resulting in aggression. These adjustment issues, or inability to navigate from one situation to another, is better known as code-switching.

Eric Deggans, in “Learning How to Code-Switch: Humbling, But Necessary,” describes code-switching as beyond the exchange of two languages in a conversation. But in today’s diverse society, the term’s deeper meaning is shifting between different cultures to move through life’s conversations. Deggans, an African American man, implies that code-switching is an essential tool for African Americans to adjust culturally. Therefore, African American males are expected to recognize one set of rules in one setting and understand another set of rules in another setting while maintaining their identity.

 

Uses with a student

We have sought to address these adjustment issues with our African American male clients through the use of play therapy methods. Using the power of imagination in play therapy allows them to foster development and problem-solve issues that have been hindering their overall academic and emotional growth. In one case, Marvel’s Superhero Avatar Creator  was used with an African American male student who was having adjustment issues at school that produced aggressive behaviors both at school and at home. Although the nature of the school setting did not permit long-term therapy, this short-term approach showed significant positive results.

This student created a superhero avatar over the course of four sessions. During the creating phase, the student used his imagination to create a creature that had similar features and skin color to his own, thus solidifying the importance of identity and connection to the creature. Allowing the student autonomy in creating his creature aided in establishing the therapeutic relationship.

The student was able to arrange the way therapy was directed as the therapeutic relationship was established. Through the various stages of play therapy, from gaining insight to reorientation or reeducation, the therapeutic process became a playground in which the student could live out his imagination through his superhero in a way that was vivid and emotionally alive. This experience paved the way for deeper understanding of how the student perceived his school family in relation to his peers, faculty and staff, and his actual family. Through incorporation of a client-centered approach to play therapy, this student showed significant growth in his overall development and was thus able to transfer those skills (i.e., code-switching) between school and family relationships.

Once significant progress was made with the student, his parents were incorporated in one play therapy session. The student’s father decided to create a superhero avatar to bring life to his perceived role as the family protector. In retrospect, through this play therapy family activity, the father could see how his family viewed his role and their individual roles within the family.

The play therapy sessions, infused with the technology of creating superheroes, helped the student use his imagination to bring to life his own unique story and identity. In superhero stories, superheroes conquer their adversaries while overcoming their adversities. The ending of this student’s story depicted similar results.

This form of play therapy is a nonintrusive method that renders promising results by not asking direct questions, but rather allowing students to self-express through play. As such, we do not believe that the traditional mode of counseling would have achieved the same impact on this child’s growth and development. This lends support to the importance of expressive therapy for children, particularly African American boys. Expressive therapies can help children find their voices, especially through play-based techniques using superhero avatars.

 

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Jetaun Bailey, a former school counselor, is a certified school counselor, a licensed professional counselor supervisor and an assistant professor at Alabama A&M University. Contact Jetaun at Jetaun.bailey@aamu.edu or baileyjetaun@hotmail.com.

 

Tonya Davis, a former school counselor, is a nationally certified school psychologist, a licensed professional counselor supervisor and an assistant professor at Alabama A&M University.

 

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Related reading: See the upcoming September issue of Counseling Today magazine for an in-depth cover article on play therapy.

 

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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.

Behind the book: Disaster Mental Health Counseling: A Guide to Preparing and Responding

Compiled by Bethany Bray July 2, 2018

Superstorm Sandy. Newtown. The Pulse nightclub. Counselors were there to help people through all of those disasters, plus countless others, both natural and human-caused, through the past decade.

Disaster mental health counseling has grown and become more standardized in the process. With each disaster, practitioners learn the subtleties of what survivors and communities most need, both immediately after the fact and in the later aftermath.

With that in mind, the American Counseling Association published an updated edition of Disaster Mental Health Counseling: A Guide to Preparing and Responding this year. The book shares insights from counselors who have served on the ground in disaster-relief efforts in a variety of situations, from work with refugees and veterans to school, university, community and international settings.

Counseling Today recently sent the book’s co-editors, Jane M. Webber and J. Barry Mascari, questions via email to learn more. Webber and Mascari are licensed professional counselors and counselor educators at Kean University in Union, New Jersey. The couple are married and present together often on disaster mental health, crisis response and trauma counseling.

 

Q+A: Disaster mental health counseling

Responses co-written by editors Jane M. Webber and J. Barry Mascari, as noted

 

As specialists in disaster mental health, you give presentations and trainings on this topic often. What are some common questions you get from attendees? What are people most concerned or curious about?

 

Mascari: The ripple effect of the growing body of evidence gets questions from various audiences, including law enforcement. So many people are interested in learning emotion regulation, and we are getting more requests to address techniques to help counselors prevent vicarious traumatization. One of my favorite questions related to these techniques is, does this stuff really work? Then they tell us how amazed they are.

Webber: Over the years at Learning Institutes on disaster mental health counseling [at ACA’s annual conference] and state trainings, one question arises quickly: What do I say or do next? Especially after events of mass violence, responders ask, how do I respond in moments of crisis or terror?

Many are fearful of retraumatizating survivors or asking intrusive questions. Counselors also ask how to integrate trauma assessment and counseling with psychological first aid (PFA) as nonintrusive, compassionate lurkers while being alert to survivors in need. Probably the question most often asked is how to respond to families after mass shootings or bombings, particularly when children are killed or injured.

 

Disaster mental health is becoming a more prevalent and growing focus within the counseling profession. Besides your book, what resources would you recommend for counselors who want to “come up to speed” in this area – especially for counselors who did not cover this topic in graduate school?

 

Mascari: Taking online courses from the Federal Emergency Management Agency (FEMA) for sure. Also, there are a lot of online programs and great books. Many of the important works have not hit the journals but are in paperbacks that appear every day. Counselors cannot operate without being trauma informed and, at best, I would certainly like to see all our colleagues become trauma competent.

Everyone works with trauma survivors. [But some practitioners] either don’t look for or ask about trauma and then treat symptoms that could be more easily resolved if the causes were addressed.

Webber: I agree with Barry: ICS 100 (Incident Command System) and ICS 700 (National Incident Management System) are FEMA organizational courses [that can help] counselors know what to expect at any disaster site anywhere in the country. The Psychological First Aid Online course provides foundational knowledge and skills for delivering PFA in the immediate aftermath of a disaster (learn.nctsn.org). A must is to download the Psychological First Aid: Field Operations Guide to your laptop. Resources and handouts in the guide’s appendices are invaluable, especially the charts with what to say to people at different developmental levels (children, adolescents, adults). Also, the TIP 57: Trauma-Informed Care in Behavioral Health Services manual is our go-to book for trauma-informed counseling. All are free.

 

Do you feel the average counselor practitioner is adequately prepared for the possibility of a disaster — either natural or human-caused — occurring in his or her community? Generally speaking, is there a “that could never happen here” mentality among counselors, or a healthier viewpoint?

 

Mascari: No! There are many skilled, well-meaning counselors who could not serve alongside other mental health responders just because they do not have the basic knowledge expected of the American Red Cross or FEMA.

PFA, the preferred FEMA modality immediately after a disaster, is not counseling in the traditional sense. Therefore, being trained to respond as part of a recognized unit means following established protocols and putting away some of the more invasive counseling techniques. This is based on the idea that people are experiencing a normal reaction to an abnormal event, and that the majority of people return to normal in a relatively short time … My students often say that they feel like their skills have been “dumbed down” [for PFA] at first, then they realize these are valuable tools and incorporate them in their counseling.

As far as the head-in-the sand view, I don’t think most counselors see it that way. We do need to do more from a leadership level to make disaster and trauma more of a priority and more central to what we do. Many times, I look at what I know and what I can do and feel like, “If I only knew this when I worked with clients a few years back.” The new skills promise “better, stronger, faster” in terms of treatment and recovery.

Webber: The misbelief of “that could never happen here” has been destroyed by the deaths of students and teachers across the country [in school shootings]. Like suicide prevention and intervention, every counselor must be trained and prepared for disaster and mass violence that might occur in our communities and schools.

 

Much has changed – in the counseling profession and the world at large – since the last edition of this book eight years ago. Briefly, tell us what it took to update the material and why you felt it was worth rereleasing this text now, in 2018.

 

Mascari: The update was a huge undertaking, basically a redo and reconceptualization of the chapters and the style of the book. It is more scholarly and evidence based and not as raw as the articles that came from the heart and experiences in the earlier book. The field is becoming professionalized, and it appeared to be time to change the focus. Our [ACA VISTAS] article on the Council for Accreditation of Counseling and Related Educational Programs (CACREP) Standards and disaster received a large number of reads, so we know other counselor educators are struggling to include these standards in their teaching. The book brings everyone up to a new standard.

Webber: We all [the book’s close to 30 contributors] worked as a mini think tank with much discussion and debate to document the rapid growth of this counseling field. It was challenging for our authors to revise and update chapters seamlessly into the book and to emphasize the critical relationship between trauma and disaster counseling.

PFA has been a vital development for disaster response. Yet, for a few years, trauma counseling and disaster response were split. We have reintegrated the practice of trauma and disaster counseling to move the profession forward.

 

What interests you, personally, in this topic?

 

Mascari: My interests are described in the book (in a section of chapter 13, “In Our Own Words: I Never Thought I Would Become So Focused on Disaster and Trauma”), but briefly: I have been responding to disaster and traumatic events throughout my career, before there was a name for this type of work.

Webber: For me, trauma-informed practice has been an ongoing commitment since I was chairwoman of the ACA Foundation during Sept. 11. Responding to disaster survivors is an existential risk that defines who I am as a counselor. I can choose to respond with courage or shy away from helping. Disaster training is essential for our profession to stay on the cutting edge of mental health counseling, especially in an era of mass violence.

 

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Disaster Mental Health Counseling: A Guide to Preparing and Responding, fourth edition, is available both in print and as an e-book from the American Counseling Association bookstore at counseling.org/publications/bookstore or by calling 800-347-6647 ext. 222.

 

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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.