Monthly Archives: May 2020

Report: More than 1 in 5 children experience bullying

By Bethany Bray May 12, 2020

Bullying, a perennial issue for professional counselors who work with young clients both in and outside of school settings, remains prevalent among American youth. Researchers have found that more than one in five American youngsters experience bullying victimization from their peers – and prevalence is higher among children under age 12.

According to data from the National Survey of Children’s Health, parents of 22.4% of children ages 6 to 11 and 21% of adolescents ages 12 to 17 report their child “is being bullied, picked on, or excluded by other children.”

The data, compiled from the 2016-2017 National Survey, was published last month in the journal Public Health Reports by researchers from the U.S. Health Resources and Services Administration.

Researchers also parsed the data state-by-state in the journal article. The prevalence of bullying varied widely, from 16.5% of children in New York to 35.9% in Wyoming. Among adolescents, it ranged from 14.9% in Nevada to 31.6% in Montana.

Bullying among children or adolescents was greater than 30% in seven states: Arkansas, Kentucky, Maine, Montana, North Dakota, South Dakota and Wyoming.

 

Read the full report in Public Health Reports:  journals.sagepub.com/doi/10.1177/0033354920912713

 

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Related reading, from Counseling Today:

Five social, emotional and mental health supports that teens need to succeed

Leading an anti-bullying intervention for students with disabilities

When bias turns into bullying

Bullying: How counselors can intervene

 

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ACA resources:

 Journal of Counseling & Development articles:

ACA practice briefs

  • Youth Bullying Prevention
  • Bullying Intervention

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Follow Counseling Today on Twitter @ACA_CTonline and on Facebook at facebook.com/CounselingToday.

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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 historical roots of racial disparities in the mental health system

By Tahmi Perzichilli May 7, 2020

Racial disparities, or unfair differences, within the system of mental health are well documented. Research indicates that compared with people who are white, black, indigenous and people of color (BIPOC) are:

  • Less likely to have access to mental health services
  • Less likely to seek out services
  • Less likely to receive needed care
  • More likely to receive poor quality of care
  • More likely to end services prematurely

Regarding racial disparities in misdiagnosis, black men, for example, are overdiagnosed with schizophrenia (four times more likely than white men to be diagnosed), while underdiagnosed with posttraumatic stress disorder and mood disorders. Additionally, concerns are compounded by the fact that for BIPOC, mental health care is often provided in prisons, which infers a multitude of issues.

BIPOC are overrepresented in the criminal justice system, as the system overlays race with criminality. Statistics show that over 50% of those incarcerated have mental health concerns. This suggests that rather than receiving treatment for mental illness, BIPOC end up incarcerated because of their symptoms. In jails and prisons, the standard of care for mental health treatment is generally low, and prison practices themselves are often traumatic.

The vast majority of mental health treatment providers in the United States are white. For example, approximately 86% of psychologists are white, and less than 2% of American Psychological Association members are African American. Some research has demonstrated that provider bias and stereotyping are relevant factors in health disparities. For nearly four decades, the mental health field has been called to focus on increasing cultural competency training, which has focused on the examination of provider attitudes/beliefs and increasing cultural awareness, knowledge and skills.

Despite such efforts, racial disparities still exist even after controlling for factors such as income, insurance status, age, and symptom presentation.Established barriers for BIPOC are the following:

  • Different cultural perceptions about mental illness, help-seeking behaviors and well-being
  • Racism and discrimination
  • Greater vulnerability to being uninsured, access barriers, and communication barriers
  • Fear and mistrust of treatment

In addition to emphasizing culturally competent services, other recommendations to bridging the gaps and addressing barriers have largely focused on diversifying workforces and reducing stigma of mental illness in communities of color.

One area not often noted is the historical (and traumatic) context of systemic racism within the institution of mental health, although it is well known that race and insanity share a long and troubled past. This focus may begin to account for how racial differences shape treatment encounters, or a lack thereof, even when barriers are controlled for and the explicit races of the provider and client are not at issue.

Historical context

In the United States, scientific racism was used to justify slavery to appease the moral opposition to the Atlantic slave trade. Black men were described as having “primitive psychological organization,” making them “uniquely fitted for bondage.”

Benjamin Rush, often referred to as the “father of American psychiatry” and a signer of the Declaration of Independence, described “Negroes as suffering from an affliction called Negritude.” This “disorder” was thought to be a mild form of leprosy in which the only cure was to become white. Ironically Rush was a leading mental health reformer and co-founder of the first anti-slavery society in America. Rush did observe, however, that “the Africans become insane, we are told, in some instances, soon after they enter upon the toils of perpetual slavery in the West Indies.”

In 1851, prominent American physician Samuel Cartwright defined “drapetomania” as a treatable mental illness that caused black slaves to flee captivity. He stated that the disorder was a consequence of slave masters who “made themselves too familiar with the slaves, treating them as equals.” Cartwright used the Bible as support for his position, stating that slaves needed to be kept in a submissive state and treated like children to both prevent and cure them from running away. Treatment included “whipping the devil out of them” as a preventative measure if the warning sign of “sulky and dissatisfied without cause” was present. Remedy included the removal of big toes to make running a physical impossibility.

Cartwright also described “dysaethesia aethiopica,” an alleged mental illness that was the proposed cause of laziness, “rascality” and “disrespect for the master’s property” among slaves. Cartwright claimed that the disorder was characterized by symptoms of lesions or insensitivity of the skin and “so great a hebetude [mental dullness or lethargy] of the intellectual faculties, as to be like a person half asleep.” Undoubtedly, whipping was prescribed as treatment. Furthermore, according to Cartwright dysaethesia aethiopica was more prevalent among “free negroes.”

The claim that those who were free suffered mental illness at higher rates than those who were enslaved was not unique to Cartwright. The U.S. census made the same claim, and this was used as a political weapon against abolitionists, although the claim was found to be based on flawed statistics.

Even at the turn of the 20th century, leading academic psychiatrists claimed that “negroes” were “psychologically unfit” for freedom. And as late as 1914, drapetomania was listed in the Practical Medical Dictionary.

Furthermore, after slavery was abolished, Southern states embraced the criminal justice system as a means of racial control. “Black codes” led to the imprisonment of unprecedented numbers of black men, women and children, who were returned to slavery-like conditions through forced labor and convict leasing that lasted well into the 20th century.

Scientific racism early on indicates motives of control and containment for profitability. Leading health professionals propagated the idea that blacks were “less than” to justify exploitation and experimentation. The mislabeling of behavior, such as escaping slavery, as a byproduct of mental illness did not stop there. Significant transformations in defining mental illness also occurred in the civil rights era, suggesting that institutional racism becomes more powerful in the context of moments of heightened racial tensions in the collective social consciousness.

Prior to the civil rights movement, schizophrenia was described as a largely white, docile and generally harmless condition. Mainstream magazines from the 1920s to the 1950s connected schizophrenia to neurosis and, as a result, attached the term to middle-class housewives.

Assumptions about the race, gender and temperament of schizophrenia changed beginning in the 1960s. The American public and the scientific community began to increasingly describe schizophrenia as a violent social disease, even as psychiatry took its first steps toward defining schizophrenia as a disorder of biological brain function. Growing numbers of research articles asserted that the disorder manifested by rage, volatility and aggression, and was a condition that afflicted “Negro men.” The cause of urban violence was now due to “brain dysfunction,” and the use of psychosurgery to prevent outbreaks of violence was recommended by leading neuroscientists.

Researchers further conflated the symptoms of black individuals with perceived schizophrenia of civil rights protests. In a 1968 article in the esteemed Archives of General Psychiatry, schizophrenia was described as a “protest psychosis” in which black men developed “hostile and aggressive feelings” and “delusional anti-whiteness” after listening to or aligning with activist groups such as Black Power, the Black Panthers or the Nation of Islam. The authors wrote that psychiatric treatment was required because symptoms threatened black men’s own sanity as well as the social order of white America.

Advertisements for new pharmacological treatments for schizophrenia in the 1960s and 1970s reflected similar themes. An ad for the antipsychotic Haldol depicted angry black men with clenched fists in urban scenes with the headline: “Assaultive and belligerent?” At the same time, mainstream white media was describing schizophrenia as a condition of angry black masculinity or warning of crazed black schizophrenic killers on the loose. A category of paranoid schizophrenia for black males was created, while casting women, neurotics and other nonthreatening individuals into other expanded categories of mood disorders.

The black psyche was increasingly portrayed as unwell, immoral and inherently criminal. This helped justify the need for police brutality in the civil rights movement, Jim Crow laws, and mass incarceration in prisons and psychiatric hospitals, which at times was an exceedingly thin line. In general, attempts to rehabilitate took a back seat to structural attempts to control. Some state hospitals, presided over by white male superintendents, employed unlicensed doctors to administer massive amounts of electroshock and chemical “therapies,” and put patients to work in the fields. Deplorable conditions went unchallenged as late as 1969 in some states.

Deinstitutionalization, a government policy of closing state psychiatric hospitals and instead funding community mental health centers, began in 1955. Over the next four decades, most state hospitals were closed, discharging those with mental illness and permanently reducing the availability of long-term inpatient care facilities. Currently, there are more than three times as many people with serious mental illnesses in jails and prisons than in hospitals. The shifts in defining what constitutes mental health reflects the reality that the definition is shaped by social, political and, ultimately, institutional factors in addition to chemical or biological ones.

Conclusion

Looking at the historical and systemic context of the mental health system may provide insight into why racial disparities continue to exist and why these disparities have been resistant to interventions such as cultural competency training and standardized diagnostic tools. Focusing primarily on the race of the provider and the client, while valid, is an approach that does not consider the system itself, the functions of the diagnosis, and its structurally developed links to protest, resistance, racism and other associations that work against the therapeutic connection.

Racial concerns, including overt racism at times, were written into the mental health system in ways that are invisible to us now. Understanding the past enables new ways of addressing current implications and identified barriers, including how schizophrenia became a “black disease,” why prisons emerged where hospitals once stood, and how racial disparities continue to exist in the mental health system today.

 

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Additional resources

 

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Tahmi Perzichilli is a licensed professional clinical counselor and licensed alcohol and drug counselor working as a psychotherapist in private practice in Minneapolis. Contact her through her website at www.tahmiperzichilli.com.

 

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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.

Mental imagery as an intervention for emotion regulation disorders

By Katie Gamby and Michael Desposito May 5, 2020

Although many evidence-based practices emphasize addressing the cognitive aspects of mental health disorders, research suggests that we may be missing helpful interventions that do not fall under the  cognitive behavior therapy (CBT) model of “thoughts, feelings and behaviors.” Several predominant CBT models fail to emphasize mental imagery by continuing to equate thoughts only with verbal manifestations. This is best seen in the counseling techniques and interventions of self-talk, thought records and the ABC (activating events, beliefs, consequences) model.

While these techniques should be lauded for alleviating the symptoms of countless clients, there are other clients who are not served by these treatments. We propose that a lack of focus on imagery can either, at best, prolong the course of treatment for clients or, at worst, encourage clinicians to label clients as “resistant” because their images insulate negative affective responses.

Most clinicians in the field tend to neglect mental imagery despite research showing that disturbances in mood and the development of certain forms of psychopathology are often correlated with negative images that contribute to the strength and production of negative emotions. Historically, mental imagery has been difficult to research and measure, but we now have evidence suggesting that mood disturbances and psychopathology can be addressed through imagery work. As professional counselors, our role is to promote a holistic approach to counseling not only by addressing our clients’ symptoms but also by focusing on the prevention of those symptoms in the first place.

Mental imagery can be defined as the representation and experience of sensory inputs without a direct stimulus. Several theories have been proposed for the creation of mental images, but bio-informational theory is the one that we will be discussing. In this theory, there is a strong connection between imagery and emotion. This connection is attributed to physical and behavioral reactions to images. For instance, negative images, in comparison with neutral images alone, often produce more negative emotional reactions (e.g., imagining yourself stuttering as you give a future speech in public increases anxiety about future speech performance).

What does neuroscience say?

From a neuroscience perspective, mental imagery is consistently implicated in the propagation of certain emotion regulation patterns. Research shows that this may occur because there is overlap between different areas of the brain based on the type of perceived image. There appears to be brain activity that overlaps between the frontal (cognitive function and voluntary movement/activity) and parietal (sensory processing) areas of the brain regardless of imagery content, but there is also some overlap between the parietal and occipital (visual processing) areas of the brain. This suggests a top-down process when retrieving information from long-term memory.

Damage to the occipital lobe can make it difficult for people to produce images, especially when they try to recall past memories. Neuroimaging also suggests a correlation between visual cortex activation and a person’s subjective rating of the vividness of an image. This could explain why it is easier for someone to recall a memory that has an emotional component to it (sometimes called a flashbulb memory).

This seems to suggest a connection between episodic memories (i.e., two people who experience the same event can have a drastically different recollection of that event) and how a negative autobiographical memory can influence future behaviors. If I continue to imagine potential future situations negatively (imagining all future speeches going poorly, for example), the likelihood is that my present and future will align with those images. If I can create a positive future image (future speeches going smoothly), I am more likely to rewrite my present, negative autobiographical memory to be more positive and, therefore, influence both my past and future self toward positivity.

Benefits for clients

Working with mental imagery in counseling offers several benefits. First, it should be noted that imagery work integrates a person’s cognitive, emotional and somatic aspects, with primary focus placed on the emotional aspect. This is important to consider because although clients might rationally “know” that something is true for them, they can still remain “emotionally stuck” in their past maladaptive behaviors. Counselors who work with images may be able to get around the rational “knowing” and actually address clients’ emotional connections to their images.

Second, imagery is often taught as a skill or to reinforce other skills. Because mental imagery connects different aspects of the brain, imagery has been shown to increase imagination and memory capacity. Additionally, teaching imagery as a skill can help clients realize their power over their own images.

For instance, both of us have used a simple image of a cupcake with a raspberry on top of it with clients. We ask clients to look at the picture of the cupcake and then close their eyes (if comfortable doing so) and imagine the cupcake in all its detail. Then we ask them to change the cupcake in the image they are envisioning, removing the raspberry and replacing it with a blueberry. By being able to manipulate the cupcake image in this way, clients can work up to practicing changing more negative images that elicit negative emotions for them. For example, perhaps clients can imagine themselves providing an eloquent speech without stuttering. Or a speech in which they stutter but are able to remain calm and collected regardless of how well they speak. There are many different ways of teaching mental imagery skills to assist clients that are outside of the scope of this article.

Third, there are several specialized areas beyond mental disorders that seem to benefit from the application of imagery work. For instance, imagery can help clients cope with current problems by allowing them to explore all sides of the issue in vivo and visualize outcomes and other alternatives. Not only can clients effectively problem-solve in this manner, they can get to the heart of emotional components that are often connected with their decisions. Mental imagery encourages clients to take into consideration the temporal nature of situations by helping to reconstruct future beliefs about identity, which in turn increases goal setting and motivation. Connecting imagery to a plan or viewing goals with imagery can increase confidence and belief that one can accomplish them.

When applied to grief work, imagery can help clients work through their grief reactions by allowing them to revisit scenes that are connected with the loss in the past. In addition, positive imagery can be promoted to help clients confront impulses in cases of nonsuicidal self-injury or even to improve outcomes of sports training. Interestingly, mental imagery has also been implicated in healing from sports injuries by decreasing subjective pain responses.

Imagery and emotion regulation

Mental imagery also plays a pivotal role in a number of mental health disorders. For example, intrusive images are considered part of the diagnostic criteria for specific disorders such as posttraumatic stress disorder (PTSD) and often are hinted at in criteria discussing “thought” processes connected to anxiety, bipolar disorder and obsessive-compulsive disorder. Typically, these distressing images match the core concerns of the presenting issue and work to insulate the distressing emotions by acting in tandem with other symptoms. Examples of this might be clients who have obsessional thoughts about insects experiencing images of insects on their bodies, clients with test anxiety experiencing future-focused images of themselves failing a test, and military veterans with PTSD returning home from active duty and reexperiencing traumatic memories during fireworks displays.

The clinical significance of understanding mental imagery when treating clients with emotional dysregulation is of utmost importance. Recent research supports the notion that when compared with verbal content, imagery elicits stronger emotion and can even have an amplifying effect. For example, when an image promotes anxiety-provoking content, it can increase a person’s anxiety. Likewise, it can amplify positive messages, such as when imagining positive outcomes through imagery rehearsal for an upcoming public speech.

Given that the “realness” of images (or a lack of image production) can influence a person’s belief in said images, it is imperative for counselors to understand the content of client images to better provide intervention strategies. Client perceptions of the “realness” of their images appear to add to the power of the content, influencing not just emotions and behaviors but also beliefs.

A strategic clinical intervention

There are several ways to promote imagery as a clinical intervention. The five specific strategies that follow are summed up based on how they can be utilized in session. These interventions, although different from each other, also overlap at times.

1) Competition to imagery: When planning counseling interventions, it can be wise to follow the adage of “fighting fire with fire” to promote the greatest reduction of symptoms in the shortest amount of time. In this instance, “competing” with tasks that use similar cognitive resources can serve to reduce the distressing vividness of the images. This is due to “overloading” the brain. The competition strategy differs from distraction coping techniques because the imagery is being processed simultaneously.

This strategy is often one of the first steps in systematic desensitization for phobias because pairing mental imagery with relaxation often has a therapeutic effect of lowering distress to the said phobia. This is because a client cannot feel both anxious and calm at the same time physiologically. It is also theorized that this is why eye-movement desensitization and reprocessing works — the clinician’s use of bilateral stimulation while the client’s image is exposed overloads the brain and reprocesses the image.

2) Exposure to imagery: One of the most common and best practice techniques occurs by exposing clients to intrusive or distressing images. The reason exposure works is because it addresses images that cause increased emotional dysregulation, allowing clients to regulate themselves over time. Eventually, the client will see an image and not have a negative emotional reaction toward it. Exposure therapy continues to show documented evidence of lowering client distress toward the images during the therapeutic protocol.

3) Imagery retraining: Retraining or “rescripting” imagery seeks to train clients to produce positive images in response to neutral environmental cues or to adapt a distressing image into a more neutral form. This is especially helpful in cases of depression because a lack of positive future images appears to insulate depression symptoms. With either method — producing positive imagery or adapting a more neutral form — the critical process seems to promote alternatives to the client’s current image or lack thereof.

In some sense, producing positive imagery is a relatively new idea. The counselor seeks to encourage the production of positive images in response to ambiguous cues to in turn help clients produce more positive images to novel stimuli. One aspect of the computerized training known as cognitive bias modification is an example of this strategy. Research suggests that this strategy alleviates depression symptoms in clients through the promotion of positive images about the future.

4) Imagery questioning: While the “realness” of mental imagery seems to predict the quality and impact of the images, another strategy used to address imagery is to examine the mental representations themselves. This is similar to the verbal thought work of CBT. With the rise of mindfulness and third-wave behavior therapies such as acceptance and commitment therapy, counselors could take a metacognitive approach to their intervention strategy for images. The object of this type of imagery is to question the “truth” of the image being reported and to promote client functioning. A client would be encouraged to go back to the image and address its truth (i.e., did everyone really laugh at me during my speech? Did I really stutter the whole time I was talking?). Now remembering the image more realistically, the client has the capacity to recall the image as it actually occurred.

5) Transformational imagery: In this work, clients are encouraged to produce an image and modify, adapt or manipulate it (rotating spatially) to promote autonomy over the image and to decrease the occurrence of distressing images. Being able to control the image allows clients to provide a safe place for themselves within a distressing image, transform the image into something different (e.g., transforming a snake into a balloon) or otherwise manipulate the image (like what we did with the cupcake mentioned earlier in the article). This is similar to imagery questioning but also promotes client empowerment to control the image themselves. Guided imagery, as a technique, is an example of this strategy in which images are transformed as an outcome of the intervention.

Steps to integrating imagery into clinical work

When addressing mental imagery in counseling, counselors should weigh the benefits and risks of incorporating the tool in sessions. As professional counselors, it is imperative that we complete thorough assessments to help us determine whether clients are stable enough to address their images. If not, it may be appropriate to first provide them with some coping tools and techniques to increase safety. Second, for imagery work to be effective, clients must be able to produce images. This is also an important piece of assessment.

A simple way to do this is by asking clients to visualize an important family member or friend who produces positive feelings in them. Then invite clients to tell you what this person looks like from head to toe. If clients do not have someone who meets this criteria, find a picture of an object, ask clients to view the picture for one minute, talk to them afterward for a few minutes, and then come back to the picture and ask them to draw that image up in their heads and tell you what they see. If clients are unable to bring back the image, they may not be appropriate for imagery work and would need further assessment.

As with any intervention we use, we need to provide our clients with appropriate informed consent and discuss the potential benefits and detriments of doing imagery work. Clients need to be informed that imagery can produce intense emotions, but providing some information about why that is might help lessen their anxiety about the process. Additionally, the therapeutic relationship is still of the utmost importance; clients must trust in the relationship to be able to get the most benefit out of therapy. Counselors may want to seek additional training to address client imagery. This can help counselors feel better prepared to engage with mental imagery and to work with clients from a variety of backgrounds. 

Conclusion

Our hope is that all counselors have access to interventions that will assist their clients in getting better. As all counselors in the field know, some interventions work seamlessly with certain clients and just don’t work with others. The more competent we are with the interventions we have to address client concerns, the more we will be able to do great work. We believe mental imagery is one intervention that professional counselors can add to their toolboxes to increase the quality of care provided to clients.

 

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Katie Gamby is a licensed professional counselor and assistant professor at Malone University in Ohio. Her research and writing interests include client wellness, mental imagery, schema therapy, and spiritual bypassing. She enjoys serving the state of Ohio through multiple professional organizations. Contact her at kgamby@malone.edu.

Michael Desposito is a licensed professional counselor at a private practice in Ohio and president of an Ohio state counseling division. He has presented at national, state and local conferences on a number of topics, including emotion regulation and mood disorders, affirmative therapy and pedagogy practices for LGBTGEQIAP+ populations, and wellness. Contact him at wellifestylecounseling@gmail.com.

 

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

 

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

Engaging avoidant teens

By David Flack May 4, 2020

Ben** is a 16-year-old high school sophomore. He completed a mental health assessment about four months ago, following a referral from his school due to behavioral concerns, poor attendance and “possible issues with marijuana and other substances.” He previously attended school-based mental health counseling in seventh grade and has been meeting periodically with a school counselor for about a year.

(** Ben is a former client who gave permission to use his story. His name and some identifying details have been changed to protect confidentiality.)

At the time of assessment, Ben was diagnosed with major depressive disorder, moderate. He also completed screening questionnaires for trauma, anxiety and various other issues. All scores came back well below clinical levels. Despite the school’s concerns regarding substances, a formal drug assessment didn’t occur.

Todd and Julie, Ben’s parents, have been divorced since Ben was 3. Ben lived with his mother until about a year ago. Todd now has full custody but frequently travels for work. Both parents have been fairly disengaged in the counseling process. In fact, Doris, Ben’s fraternal grandmother, was the only family member to attend the assessment.

At the assessment, Doris appeared overly enmeshed with both Ben and Todd. She also reported that Julie “has bipolar but won’t take any meds” and “drinks too much, at least if you ask me.” Doris also stated that Ben “probably was abused” by Julie’s ex-boyfriend but refused to provide further details. “I don’t think I should have said anything.”

Following the assessment, Ben entered services reluctantly, meeting with his original counselor for almost two months. At that time, he was referred to me because the original counselor decided, “I can’t be effective with such a resistant kid.” The counselor said Ben’s attendance was poor and that he displayed an unwillingness to engage when present, did not complete treatment homework, and “showed up high at least a few times.”

During our first meeting, Ben reported, “All that other therapist did was keep saying how her office was a safe space to talk about feelings and crap like that. You know, the bullshit therapists always say. The bullshit I bet you’ll say too.”

Numerous studies show that an effective therapeutic alliance is essential for engagement, retention and positive treatment outcomes. However, many teenage clients simply aren’t interested in counseling, let alone creating connection or building rapport with some strange adult. This is especially true when it comes to avoidantly attached teens such as Ben.

Building effective therapeutic alliances with these youth can seem daunting to even the most seasoned counselor. In this article, we’ll explore practical, field-tested strategies for cultivating rapport with avoidantly attached teens. First, though, let’s briefly review some core attachment ideas.

We aren’t sea turtles

When a mother sea turtle is ready to lay eggs, she heads to a beach and digs a hole in the sand with her rear fins. She lays her eggs in this rudimentary nest, covers them, and quickly returns to the ocean. At this point, the mother sea turtle has completed all her parenting tasks and has nothing more to do with the eggs. Male sea turtles have nothing at all to do with their offspring.

When the eggs hatch, the newborn sea turtles awkwardly scamper to the ocean, using fins meant for swimming, not avoiding predators on land. If they survive this mad dash, they’re fully ready to live on their own. No caregiver ever provides nurturing, teaches them life skills or protects them in any other way.

Humans aren’t sea turtles. In our early years, we need caregivers just to survive. If these caregivers are attentive, protective and nurturing, human babies quickly learn that the world is a safe place, their needs will be met and people are glad they’re here. These children will be securely attached. However, if their primary caregiver isn’t dependable, then this healthy attachment process can be disrupted, resulting in an insecure attachment and possibly lifelong challenges with relationships, self-esteem and personality development.

There are three styles of insecure attachment: avoidant, anxious and disorganized. Avoidant attachment is the most common style of insecure attachment, with studies indicating that up to 1 in 4 Americans fall into this category. Undoubtedly, this percentage is higher in clinical settings.

Young children who develop an avoidant attachment style predictably have caregivers who are emotionally unavailable and ignore the child’s needs. These caregivers may reject the child when hurt or sick, typically encourage premature independence, and sometimes are overtly neglectful. As a result, the child learns, “I’m on my own.”

Attachment styles are continuums, so avoidantly attached teens don’t all act the same. That said, these youth often appear defiant, defensive or dismissive. They’re likely to present as highly independent, oppositional and unwilling to change. They’re also likely to be suspicious of any empathetic gesture.

A little more about empathy

Simply put, empathy is the ability to understand the feelings of another person. As counselors, we’re taught that empathy is an essential component of all effective therapeutic relationships. I certainly don’t disagree with this. However, it seems to me that empathetic gestures are far from one-size-fits-all.

With reluctant clients of all ages, many counselors demonstrate empathy by saying things such as, “Seeking support is a courageous step” or “My office is a safe space to explore your feelings.” It’s like turning the volume up on some secret empathy knob. With anxiously attached clients, this could be quite effective. For avoidantly attached teens though, this is often overwhelming. Life has taught these youth to be cautious of such statements. So, when they hear such statements, they retreat.

I’m certainly not suggesting that we turn our empathy off as counselors. However, in the early stages of building therapeutic alliances with avoidantly attached teens, we need to turn the volume down. With this in mind, don’t congratulate avoidantly attached teens for starting counseling, especially if doing so is simply their least bad choice, and don’t declare your office a safe space. They know better.

I believe this more nuanced perspective of empathy is an essential foundation for engaging in the attachment-informed strategies that follow.

Starting out right

With avoidantly attached teens, first impressions are essential for starting out right. Here are four tips to help ensure that first meetings are therapeutically productive:

Emphasize rapport building. First meetings often involve stacks of paperwork, required screening tools and initial treatment planning. I encourage you to put that stuff aside and spend time getting to know the teen sitting across from you. You’ll have to finish all those forms eventually, but if this new client never returns, tidy paperwork and a well-crafted diagnosis won’t matter much. Besides, you’ll get better answers from teens such as Ben once you’ve developed some rapport.

Get parents out of the room. Unlike Todd and Julie, parents or caregivers almost always attend first meetings. When they do, I meet with everyone to cover the basics, such as presenting concerns, my background, and confidentiality issues. I then ask parents what they think I should know. After I get their perspective, I have them leave. That way, most of the first meeting can be focused on learning what the teen wants from services and cultivating rapport.

Focus on what they’re willing to do. Therapists love to focus on internal motivators and lofty treatment goals, but this isn’t useful with avoidantly attached teens, who want one thing — to leave and never come back. You’ll get further by helping them identify external motivators, such as fulfilling probation requirements or keeping parents happy. Helping avoidantly attached teens move toward these concrete goals proves that you’ve actually listened to what they’ve said, makes you an ally, and keeps them coming back.

Don’t hard sell therapy. When confronted with resistant clients, it’s easy to overstate the advantages of engagement. After all, if we didn’t believe in therapy, we wouldn’t be therapists, right? However, our enthusiasm may be exactly what an avoidantly attached teen needs to justify a quick retreat. Instead, objectively present your treatment recommendations, then explore the pros and cons of engaging. In my experience, most avoidantly attached teens agree to services when they don’t feel coerced.

With the first meeting successfully concluded, our next task is to cultivate an effective therapeutic alliance. Edward Bordin (1979) wrote that the therapeutic alliance is composed of
1) a positive bond between the therapist and client, 2) a collaborative approach to the tasks of counseling and 3) mutual agreement regarding treatment goals. When we strive to fully integrate these elements and genuinely embrace a teen’s motivators, we stop being an adversary and become an ally. For avoidantly attached teens, we also become a much-needed secure base — maybe their only one.

Building a strong therapeutic alliance with avoidantly attached teens requires us to focus on being trustworthy and creating connectedness.

Trustworthiness

Avoidantly attached teens have learned to continuously question the honesty of others. As a result, it is essential for us to be absolutely impeccable in our trustworthiness as counselors. It isn’t enough simply to be trustworthy though; we must demonstrate it — and not just once or twice but during every single interaction.

Brené Brown (2015) likened trust to a jar of marbles. Every time that we demonstrate our trustworthiness, we put a metaphorical marble in the jar. As the jar fills, trust grows. When it comes to building therapeutic alliance with avoidantly attached teens, there are five especially important marbles:

Authenticity. In the context of therapeutic alliance, authenticity means being our true, genuine selves during interactions with clients. In other words, we set aside therapeutic personas and canned responses. Instead, we show up as who we really are. This should be our goal with all clients but especially so with avoidantly attached teens, who are often quite sensitive to insincere behaviors or actions — a skill they learned to help them navigate difficult relationships with the adults in their lives.

Consistency. Being consistent means acting in ways that are predictable and reliable, something avoidantly attached teens probably haven’t experienced much. When we are consistent in our interactions with these teens, we are not only demonstrating trustworthiness but also modeling a new way of being in relationships. A few ways to demonstrate consistency include always starting and ending sessions on time, scheduling appointments at the same time every week, and following through on any promises we make.

Nonjudgment. Avoidantly attached teens have often learned to notice seemingly minor cues, such as a slight change in facial expression. This is a useful skill to have in situations in which care is unpredictable. With that in mind, it is important for us to avoid comments, gestures or facial expressions that could be interpreted as judgmental. This seems obvious but can be harder than it sounds, especially when a client is frustrating, evasive or baiting us — you know, like teens do sometimes.

Usefulness. Another way to demonstrate trustworthiness is to provide something useful at every session. This doesn’t mean achieving a major clinical breakthrough every week. That wouldn’t be realistic. However, there should be a tangible takeaway of some sort each time that we meet with an avoidantly attached teen. Possibilities include a helpful skill, a solved problem, an opportunity to vent or a meaningful insight — as long as it adds value to the youth’s life.

Transparency. This means being completely open about the therapy process, including our intentions as a helper and what clients should expect from services. Truly transparent therapists spend time exploring the pros and cons of counseling, reasons for discussing certain topics, and the theoretical underpinnings of proposed treatment approaches. In other words, transparent therapists strive to eliminate the mystery from the process. Like a good magic trick, knowing how it works should make it more engaging.

Connectedness

According to Edward Hallowell (1993), connectedness is “a sense of belonging, or a sense of accompaniment. It is that feeling in your bones that you are not alone.” I often describe this deep connectedness as feeling felt. In order for any of us to truly feel felt, we must believe that we are understood, respected and welcomed. We must feel as though we’re interacting with another person who has purposefully chosen to join us in this exact place and moment.

Avoidantly attached teens haven’t had this lived experience of connectedness. When working with these teens, we should always strive to model connectedness in ways that honor their implicit suspicion of empathy, while simultaneously helping them move toward more secure attachment styles.

Allan Schore (2019) refers to these as “right brain to right brain” connections. We can intentionally create such connections by using approaches that focus on emotion, creativity and attunement. It seems to me that teen therapy typically focuses on problem-solving, decision-making, psychoeducation and similar left-brain approaches, ignoring the importance of helping clients become more comfortable using their whole brain.

Here are five simple yet effective strategies for intentionally fostering right-brain connections:

Validate and normalize. Viewed in the context of his lived experiences, Ben’s distrust, oppositional behavior and even substance use were functional. In other words, Ben found value in these behaviors. In fact, he once said, “I guess what I really want is to push people away, and I’m good at it. Really good!” We can validate intentions without endorsing problematic behaviors. With avoidantly attached teens, this is often an essential step to building therapeutic alliances.

Use first-person plural language. The words we use matter. Here’s one example: Instead of using the pronouns “you” and “your,” shift to “we” and “our.” This shift results in a subtle, yet tangible, change in our interactions with avoidantly attached teens. It also helps reinforce that we’re together in the process and that the teen’s experiences are understandable. I’m not sure that clients overtly notice this word usage, but I definitely believe there is value in making the shift.

Use more reflections, ask fewer questions. Most therapists ask way too many questions. To an avoidantly attached teen, questions can seem intrusive, annoying and disingenuous. It may seem counterintuitive, but fewer questions from you will actually result in more talking by the client. Instead of all those questions, use reflections. While you’re at it, avoid cautiously worded reflections. Instead, commit to what you’re saying, with statements of fact such as, “That was tough for you.” Such statements demonstrate connection, not interrogation.

Talk less, do more. From a developmental perspective, full-on talk therapy isn’t the best fit for teens, especially for avoidantly attached ones who don’t want to engage in the first place. I suggest incorporating some no-talk approaches for building rapport and addressing therapeutic goals. The card games Exploding Kittens and Fluxx are excellent choices for building rapport. They are teen-friendly, easy to learn and filled with opportunities for making metaphors. Favorite therapeutically focused activities include collages, creative journaling and walk/talk sessions.

Be fully present. Being present means having your focus, attention, thoughts and feelings all fixed on the here and now — in this case, the current session with the current client. From my perspective, this requires more than a basic attentiveness. It requires being fully engaged, human to human, with no judgment or agenda. This level of presence can feel risky at times, for counselors and for avoidantly attached teens. However, the connectedness it brings makes the risk well worth taking.

Relationships are reciprocal

Imagine your response if a client reported being in a relationship in which the other person refuses to share personal information and frequently makes statements such as “I’m curious why you want to know that,” even when the question is fairly innocuous. Perhaps you’d amend this client’s treatment plan to include working on healthy relationships or building appropriate boundaries. I sure would. Yet, this is what we do all the time as counselors, based perhaps on an assumption that self-disclosure is inherently bad.

It seems to me that we shouldn’t expect teens, especially ones who are avoidantly attached, to be open with us if we aren’t open with them. I’m certainly not suggesting that we share every detail of our lives with teen clients, but I do believe we should be willing to disclose relevant information, answer questions asked out of true curiosity, and be as honest with clients as we expect them to be with us. By doing so, we model effective interpersonal skills, demonstrate healthy ways to connect with others, and solidify the therapeutic alliance.

When teen clients ask questions of a personal nature, some therapists view this as a form of resistance, as a way to avoid the topic at hand or as behavior that interferes with treatment. I disagree, at least sometimes. Perhaps the teen is making an initial attempt to cultivate a relationship with us. Perhaps these questions are a sign that we’re becoming a secure base for the teen. Perhaps we’re witnessing a little nugget of change. Why would we shut that down?

When we deflect all questions of a personal nature, maybe we aren’t reinforcing appropriate therapeutic boundaries or challenging client avoidance. Maybe we’re rejecting a tentative attempt at connection. Maybe we’re demonstrating that we aren’t a secure base. Maybe we’re reinforcing the client’s avoidant attachment style.

For the first several weeks, sessions with Ben were slow going. He often showed up late, sometimes refused to talk and frequently stated he didn’t need or want help. One day, I taught him Fluxx. He commented that the game was about unpredictability. “I hate that,” he said.

The next session, Ben brought his own game, Unstable Unicorns. “It’s a complicated game,” he said, “but I’m a complicated person, and you seem to understand me.”

I let that register, picked up my cards, and lost three games in a row. At the end of the session, for the first time ever, Ben said, “See you next week.”

John Bowlby (1969) described attachment as a “lasting connectedness between human beings” and stated that the earliest bonds formed by children with their primary caregivers have significant, lifelong impacts. When meeting with avoidantly attached teens, it’s essential that we remember the ghosts in the room with us. It’s essential that we intentionally earn marbles. It’s essential that we slowly, but steadily, create connectedness. When we do, we invite teens such as Ben to move toward a more securely attached way of being.

 

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David Flack is a licensed mental health counselor and substance use disorders professional located in Seattle. For 20 years, he has met with teens and emerging adults to address depression, trauma, co-occurring disorders and more. In addition to his clinical work, he regularly provides continuing education programs regionally and nationally. Contact him at david@davidflack.com.

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

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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.

Supporting families on their autism journeys

By Lindsey Phillips May 1, 2020

Maria Davis-Pierre, a licensed mental health counselor (LMHC) in Lake Worth, Florida, first suspected her daughter might be on the autism spectrum when she was 6 months old and showed signs of sensory issues. Then at 10 months, her daughter, who had been saying simple words such as “mama,” “dada” and “ball,” suddenly stopped speaking. When Davis-Pierre and her husband tried to get their daughter to mimic them saying the words, she acted as if she had forgotten them. As a therapist, Davis-Pierre understood the importance of early intervention, so she was proactive about getting her daughter a diagnosis. But it wasn’t easy.

Her pediatrician referred her to health professionals who specialized in developmental delays in infants and toddlers. They tested her daughter and thought she had autism spectrum disorder (ASD), but because she was still so young (around 18 months), they didn’t feel comfortable officially diagnosing her. They recommended she see a pediatric neurologist.

After more tests (which cost the family thousands of dollars out of pocket), the pediatric neurologist agreed about the presence of ASD but was also uncomfortable officially diagnosing the child at such a young age. Davis-Pierre told the doctor she was going to sit in his office every day until her daughter got a diagnosis. One week later, that finally happened.

Davis-Pierre thought the next steps would be easy, especially given that both she and her husband are in the health care field. But what she experienced was more frustration.

“At no point — even with the neurologist — was there a check-in with the parent: ‘OK, this is the diagnosis. This is what happens next,’” Davis-Pierre recalls. “It was, ‘OK, here’s your paperwork. This is the diagnosis. Now, go figure it out.’” According to Davis-Pierre, the health care professionals didn’t provide her family with resources or give any consideration to how the family’s culture would factor into their daughter’s treatment.

When Davis-Pierre spoke with other parents of children on the autism spectrum, she found out that this treatment was the norm. And it left her — and the other parents — feeling overwhelmed.

This experience prompted Davis-Pierre, an American Counseling Association member, to start Autism in Black, a private practice that specializes in helping black parents of children with autism get the help they need.

In a blog post on the website GoodTherapy, Janeen Herskovitz, an LMHC in Ponte Vedra Beach, Florida, points out four areas in which counseling can help parents of children with ASD: adjusting to the diagnosis (which is often traumatic for parents), learning parenting skills, staying connected to their partners, and managing stress. Professional counselors can also help families prepare for developmental transitions, learn to effectively communicate with one another and extended family, and navigate cultural barriers.

Working through developmental transitions

ASD “is a neurodevelopmental disability, which means at different developmental stages, our clients are going to run into different developmental barriers, and they’re going to need us as counselors,” says Chris Abildgaard, a licensed professional counselor and director of the Social Learning Center in Cheshire, Connecticut. So, it’s important for counselors to understand where families are on their journeys, he points out. Is the family adjusting to the diagnosis? Are they struggling to communicate with their child? Are they helping a child through puberty? Counselors should also prepare to help families with life milestones such as going to prom, getting a driver’s license or grieving a death, Abildgaard adds.

Some families experience grief when they first learn about the ASD diagnosis, says Michael Hannon, an assistant professor of counseling at Montclair State University in New Jersey. These families will be reconciling a new reality and having to let go of certain elements of the relationship they expected to have with their child. “It’s really about [the family] learning to adjust to the needs, strengths, capacity, and some challenges of the people they love living with autism,” he adds.

Another challenging transition for parents and caregivers is when the child enters adulthood. Parents have likely been involved in every aspect of the child’s life, especially in the school system, so it is a significant adjustment when the child takes over this responsibility, Davis-Pierre says. She helps ease this transition by having parents teach their children to advocate for themselves before they reach adulthood. The more parents involve children with ASD in the day-to-day decisions about their lives and school, the more they realize that their children are capable of advocating for themselves, she says.

Abildgaard, an ACA member who specializes in ASD (and author of the 2013 Counseling Today article “Processing the ‘whole’ with clients on the autism spectrum”), has noticed that families sometimes push their child to do something that the child isn’t ready for or doesn’t want. For example, parents often ask him how they can make their child have a friend. Counselors need to educate parents that relationships take time and that individuals on the spectrum may not fully understand the intricacies of relationships and friendships. They will need support and coaching in this area well into their late teens, early 20s or beyond, he says.

Counselors can also help parents make plans and prepare for certain life events and developmental transitions, Abildgaard says. He finds visuals useful in helping families with a child on the spectrum to process events. Recently, he had a family who was going on a trip to a large city. He brought out his whiteboard and on one side wrote down all the thoughts and feelings the parents were having about the upcoming trip, such as feeling anxious that their child would have a tantrum and run from them. Then, Abildgaard asked the parents to consider their child’s perspective and why he might have a tantrum. On the other side of the whiteboard, he wrote down the child’s thoughts and feelings, such as being overwhelmed by all the lights and sounds.

This activity helped the parents realize the link between their own thoughts, emotions and behaviors and those of their child. It also started a discussion about proactive strategies the parents could take to decrease the likelihood of their child experiencing sensory overload. This, in turn, lowered their anxiety about the trip, Abildgaard says.

Helping families stay connected

Having a child with autism affects the entire family system, Abildgaard says. It affects how parents interact with each other, how parents interact with each of their children, how siblings interact with each other, and how the family interacts with extended family members.

Couples don’t typically preemptively discuss the possibility of a having a child with a disability, Davis-Pierre notes. So, when a child is first diagnosed with autism, parents often have to reassess the roles, expectations, responsibilities and core values of the family, she says.

Counselors may also have to coach families through complicated life events such as divorce. Abildgaard, an adjunct professor in the Department of Special Education at the University of Saint Joseph, reminds counselors that regardless of the situations that families bring to them, it is important to break these situations down into manageable parts for the clients.

When the parents of a client with ASD were going through a divorce, Abildgaard, a nationally certified school psychologist, brainstormed with the parents how best to explain the situation to their son. Abildgaard also learned from the client’s school that the child had been making comments about the divorce there. Abildgaard says his role as a counselor was to help the client process and express his feelings about the divorce. To do this, he said, “Tell me some things your eyes are noticing that are different at home.” He made his language concrete and specific, which allowed the child with ASD to talk about what he had been noticing, such as his parents arguing more. The boy also said he was scared to talk about these things with his parents, so he and Abildgaard worked through his anxiety together.

Then, Abildgaard brought the entire family into his office to discuss these issues. He chose to have them come in during the morning hours when his office would be quiet so the family would be more comfortable and not feel rushed or distracted.

Balancing the parenting of both neurotypical and neurodiverse siblings is another common challenge that Hannon and Davis-Pierre hear about from their clients. They try to help parents learn how to better communicate with their children and to maximize and be intentional about the time they spend with each child.

Hannon, a licensed associate counselor in New Jersey, uses empathizing strategies to help parents understand what their neurotypical child is feeling. For instance, he asks, “What would your neurotypical child say about this experience right now?” and “What would the child say about how you attend to the sibling with autism compared to how you attend to his or her needs?” This exercise allows parent to empathize and reconcile some outstanding issues with their neurotypical children, he explains.

Davis-Pierre’s clients also report struggling to know how to engage with their neurodiverse children. “We’re so used to looking for [the child to verbalize] … the actual feeling that we’re not looking at the behavior of what the child is showing,” she says.

She has parents role-play to gain perspective on what the child might be thinking or feeling and to increase awareness of behavioral patterns. (For example, Davis-Pierre has noticed that her daughter expresses happiness by flapping her arms and spinning in circles.) If appropriate, she has the child role-play with the parent, but if that is not possible, Davis-Pierre does it herself. To increase understanding, parents can also keep a behavioral journal or use the picture exchange communication system, which allows individuals with little or no verbal communication to present a feeling card to communicate their feelings, Davis-Pierre adds.

Children on the spectrum pick up on their parents’ and caregivers’ emotions more often than people think, Abildgaard points out. However, if they do sense these emotions, they often don’t know what to do with them. Children on the spectrum may appear to be ignoring the person or emotion, but in many cases, they just don’t have the language or perspective-taking ability to process the emotion and the “right” response to it, he explains.

So, Abildgaard works with parents to help them process their own emotions and then explain those emotions to their children so they aren’t left to interpret them on their own. In fact, parents can overtly model how to handle certain emotions such as anger or frustration. Abildgaard often suggests that parents (especially those with younger children on the spectrum) put themselves in “time out” to show their children that even adults need breaks.

Cultural implications

According to a 2014 report from the Centers for Disease Control and Prevention, 1 in 59 children in the United States have been identified with ASD. But this number doesn’t take into consideration cultural and racial implications such as delayed diagnosis. According to a 2019 news report on Spectrum, which bills itself as “the leading source of news and opinion on autism research,” black children with autism are often diagnosed later than white children, misdiagnosed more frequently with other conditions such as behavioral problems or intellectual disability, and underrepresented in studies of autism.

Hannon attributes the disparities in diagnosis rates to 1) inequalities in access to health care, 2) mistrust of health care systems among people of color and 3) greater misdiagnosis of symptoms in minority children as behavioral rather than developmental.

Davis-Pierre says the history of racism and discrimination in U.S. health care may persuade some black families not to be completely honest with health care professionals when discussing their children because they fear their children will be taken away. For example, frustration and exhaustion are normal responses for families caring for a child on the autism spectrum, perhaps leading someone to say or think to themselves in a particular moment, “I just can’t do this another day.” But many black families fear serious repercussions should they admit to such passing thoughts with a counselor, Davis-Pierre explains.

Even the treatments families choose for their children are often informed by one’s culture. Applied behavior analysis (ABA) aims to help individuals on the spectrum increase behaviors that are helpful and reduce behaviors that may be harmful to them by positively reinforcing desired behaviors. Debate has swirled, however, over whether ABA is helpful or harmful. According to a 2016 article on Spectrum, some have criticized the therapy for being too harsh in how it corrects maladaptive behaviors and for attempting to make people on the spectrum “normal” instead of advocating for neurodiversity.

But for some families, Davis-Pierre says, ABA makes sense. For example, a black child spinning in circles and banging his head against something in public will often be viewed differently than would a white child who exhibits the same behavior. In this instance, ABA can help protect the black child by helping him learn to replace the maladaptive behavior — one that could put him in danger — with a more socially accepted behavior, Davis-Pierre explains.

The harsh reality is that black people often have to operate differently in public settings because of prejudice and racism, she continues. So, she advises families to consider their child’s behavior and safety when choosing the best treatment for their child’s autism.

Davis-Pierre, author of Self-Care Affirmation Journal and Autism in Black, also finds that clinicians often don’t respect the culture of the home when treating children who are on the spectrum. A client once told Davis-Pierre that she had a therapist come into her home and not remove their shoes despite seeing a place for them by the front door. This act made the parent feel disrespected, and she no longer wanted the therapist in her house working with her child.

Another of Davis-Pierre’s clients was upset by a therapist who had made a decision involving her child without consulting the mother first. While the therapist and child were working together in the family’s home, the child wet himself. The therapist wanted to help the parents by changing the child herself. When the mother discovered that the therapist had gone through her child’s clothes drawers to find clean underwear, she felt as if the therapist had been snooping.

Abildgaard says his role as a counselor is to help clients on the autism spectrum adapt to different social situations and understand social context and social norms for particular settings and cultures. Counselors need to be aware of clients’ cultural and religious norms before instilling certain perceived social skills such as maintaining eye contact, he says. For example, as Abildgaard points out, some Asian cultures make eye contact only with certain people or in certain situations. So, counselors should understand the whole child before prioritizing what social skills or competences are most relevant to focus on in session, he asserts.

Religious beliefs can sometimes pose another barrier to seeking treatment. For instance, Davis-Pierre says, people in the black community are often taught to pray about their problems and not to discuss problems with anyone outside of the family. Counselors may assume that families who aren’t willing or enthusiastic participants in therapy are resistant, but as she points out, they may actually be having an internal struggle between seeking counseling and feeling that they are still maintaining their faith in God.

Davis-Pierre often uses genograms to help clients identify family patterns, such as other family members with a developmental disorder, or cultural values that have been passed along that no longer work for the family. Through genograms, she has noticed that her clients’ families often inherit a pattern of keeping secrets that hurts, rather than helps, the family dynamic. Davis-Pierre acknowledges that even she had a difficult time explaining to her extended family why she and her husband are so vocal about their daughter being on the autism spectrum.

Hannon and Davis-Pierre say that counselors have to be brave and willing to talk about clients’ and families’ cultures and about inequalities based on race and ability status. Starting this conversation can be as simple as including a question such as “What cultural traditions should I take into consideration?” on the intake form, Davis-Pierre says. This question shows that the clinician is already thinking about how culture affects treatment, she explains.

Supporting dads

Abildgaard argues that fathers are often overlooked when thinking about an autistic individual’s support network, so mental health professionals must do a better job of incorporating dads into the therapeutic process. He has noticed that mothers with children on the spectrum are often more proactive about independently finding and supporting each other, whereas fathers, even though they are involved in their children’s care, don’t tend to form support groups on their own. Abildgaard suggests that counselors could offer focused support services such as fathers’ groups or “dad’s night out” events to help these men learn from and bond with other fathers in similar situations.

Such support groups matter when it comes to providing care to individuals on the spectrum. Hannon, an ACA member who specializes in the psychosocial aspects of autism on fathers and families, often co-leads a group for fathers who have children with ASD. These men have reported that just being connected with other fathers who share similar experiences can be life-changing. In these groups, dads find others who speak their language and understand their journeys, which makes them feel heard, Hannon says. Groups also help fathers become more aware of their own needs and challenges and discover effective coping and adjustment strategies, he adds.

Fathers also spend a significant amount of time thinking about their children’s prognoses, their children’s futures, and the ways they can prepare their children to live full lives, Hannon says. In his dissertation, he studied the experiences of black American fathers of individuals with autism. At the ACA 2018 Conference & Expo, Hannon presented his findings from a grounded theory study on how diverse fathers orient themselves to their children’s diagnoses. Fathers often want to help their children who are on the spectrum, he continues, but if they have been raised with certain gendered expectations, counselors may need to take a few extra steps to help these dads increase their efficacy with day-to-day activities such as helping with temper tantrums.

Counselors may also need to help fathers retain focus on their emotional journeys because men are often task-oriented in how they solve problems, Hannon points out. Also, because men have often been socialized to engage only with specific emotions such as lust and anger, counselors may have to dig deeper with them to reveal the other underlying emotions. For example, counselors could suggest, “You’re angry, but it sounds like the source of your anger is fear for your child’s safety.”

Generational pushback

Parents sometimes face generational challenges in caring for their children. Hannon describes a common scenario that fathers often share with him: They leave their children in their grandparents’ care, providing suggestions for ways to best communicate with the children and guidance on particular eating preferences. To which the grandparents might respond, “We’re not doing any of that. We’ll do what we want with our grandchildren. They just need a good talking to.”

Such scenarios often leave parents of children on the spectrum feeling frustrated. If the parents and grandparents have a good, healthy relationship, then counselors can help parents learn to communicate openly and honestly with the grandparents. Hannon advises parents to lead with love and acceptance before critiquing the grandparents’ interaction with the children. Parents can first emphasize how the grandparents love their grandchildren before saying that they just want to show them additional, special ways to show love to a grandchild on the spectrum. 

When Abildgaard works with grandparents who need help accepting their grandchild’s diagnosis of ASD, he starts by saying that he could use the grandparents’ help to allow him to better understand their grandchild. Once this barrier is broken down, he finds that grandparents tend to ask more questions and start honest dialogues about grandchildren who are on the spectrum. 

Counselors can also help clients realize that while it is OK to establish boundaries with extended family, they should aim to set realistic boundaries that honor both the child on the spectrum and the family, Davis-Pierre says. For example, if a family depends on grandparents to provide child care, then the family must be particularly careful in setting boundaries. At the same time, the family can still have a respectful conversation with the grandparents about the needs of the child and family.

Adjusting language

Abildgaard’s clients with ASD sometimes complain that their parents always ask the same question after school: “How was your day?” Because, from their perspective, their days are always the same, the children wonder why their parents ask something they already know the answer to. 

Abildgaard advises parents to instead use concrete language such as “Tell me two good things about your day and one thing you would have changed.” This phrasing gets to the heart of what parents actually want to know from their child and makes the conversation more productive, he says. 

Abildgaard is also careful about the language he uses with clients with ASD and their families. Recently, the mother of one of his clients (a boy in sixth grade) told him that her son ran out of his classroom at school. When the boy walked into his office, Abildgaard said, “Tell me two good things about your day and one thing you would have changed.” This prompted the client to tell Abildgaard he had run out of his classroom.

After admitting this, the boy looked at Abildgaard, seemingly waiting to be chastised. Instead, Abildgaard asked the boy, “What do you think I’m thinking right now?”

The boy responded, “You’re thinking you are mad at me.”

Abildgaard drew a thought bubble on a whiteboard and wrote the client’s thought inside the bubble. Then he drew another thought bubble and wrote what he was actually thinking: “I’m wondering what made him run out of the room.”

The boy’s body language instantly relaxed. This exchange took Abildgaard out of the authoritarian role and shifted the conversation from focusing on the problem to focusing on how to solve the problem.

Similarly, Hannon recommends that counselors focus on strengths, and not just deficits and challenges, when working with families who have a child on the spectrum. He makes a point of asking parents about the victories they have had that week or month.

This question prompted one of Hannon’s clients to share how his son had used appropriate language and displayed empathy — a skill the child had previously struggled to demonstrate — that week.

The child’s mother had said, “I’m going to run through the shower.”

The child on the spectrum responded, “No, you can’t do that because you’re going to fall.”

Even though the child hadn’t grasped the true meaning of his mother’s words, he had shown concern for his mother and responded appropriately, which was a huge victory for this family, Hannon says.

Support often makes all the difference. Davis-Pierre and her family’s autism journey may have had a challenging start, but they eventually found health care providers who worked with them as a team. With this support, Davis-Pierre and her husband were able to stop focusing so much on the challenges and instead start enjoying their child for who she is.

 

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Lindsey Phillips is a contributing writer to Counseling Today and a UX content strategist. Contact her at hello@lindseynphillips.com or through her website at lindseynphillips.com.

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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.