Tag Archives: Children & Adolescents

Behind the Book: Solution-Focused Counseling in Schools

By Bethany Bray November 2, 2015

One of the many reasons solution-focused counseling is a good fit for school settings is because it’s a client-directed approach, says John Murphy, a longtime school psychologist and author of Solution-Focused Counseling in Schools.

School counselors often find the bulk of their time consumed with noncounseling tasks. When they Branding-Box-Solutionare able to meet with a student, using a solution-focused approach provides a customizable way to forge a therapeutic bond with the young person in a short amount of time.

“The simple and practical premise of solution-focused counseling – find what works and do more of it – is one of its most appealing features for school practitioners,” Murphy writes in the book’s conclusion. “This does not mean, however, that it is easy to do. Solution-focused work requires careful attention to language, client feedback, relationship building and other therapeutic nuances and skills. Mastery of these skills requires patience and practice. If your experience is anything like mine, however, it is well worth the effort.”

Solution-Focused Counseling in Schools was originally released in 1997; the American Counseling Association published a third edition of Murphy’s book earlier this year.

 

Q+A: John Murphy on Solution-Focused Counseling in Schools

In the book’s introduction, you write “schools are not set up to accommodate counseling.” Can you elaborate on what you mean by that?

This is not a criticism, merely an observation that the main purpose of schools is to teach reading, writing, math and other important academic skills. Unlike mental health centers and private practice settings where counseling is the main focus and the physical setting reflects that focus, school settings present some unique challenges for counselors.

These challenges include working around students’ and teachers’ busy class schedules, safeguarding client confidentiality and conducting “counseling sessions” whenever and wherever you can — in the lunchroom, on the playground, talking with a parent by phone or walking alongside a student or teacher in the hallway. This requires a lot of flexibility on the part of school practitioners.

But let’s not forget that there are advantages to school-based counseling as well. In addition to offering instant access to students and teachers, schools provide a natural and familiar setting for students and parents who might otherwise have to leave their community and travel long distances to receive services. For these reasons, and the fact that we know more than we ever have about helping people change, I ended the new edition of Solution-Focused Counseling in Schools by stating that there has never been a better time to be a school-based counselor.

 

From your perspective, what makes a solution-focused approach effective in helping elementary through high school students? How is it a “good fit”?

For starters, solution-focused counseling (SFC) is a clear and practical approach that makes sense to students, caregivers and counselors. Research tells us that people are more likely to benefit from counseling approaches that make sense to them, that respect their input and goals, and that customize counseling to them rather than requiring them to conform to the counselor’s preferred methods. SFC meets all of these criteria, which explains why it is effective with students of all ages.

Although solution-focused counselors validate problem-related experiences and struggles, they gently invite students to take action instead of spending a lot of time analyzing the problem. The “less talk, more action” nature of SFC seems to appeal to students as well as school counselors, who have very little time to do counseling in the first place.

Another reason SFC works with students is because it grabs their attention as “something different” rather than more of the same. Most students with school problems are well accustomed to problem-focused conversations with adults. These well-intentioned conversations emphasize what is wrong with students, with little or no attention to what they are doing well, which may include coping with a problem or preventing it from getting worse. In contrast, solution-focused conversations seek out students’ strengths and resources and explore how these assets could be applied toward solutions. In my experience, conversations that recognize and build on what is right and working with students engage their participation more effectively than “more of the same,” problem-saturated discussions.

The solution-focused approach fits with school counselors as well. In teaching classes and workshops throughout the U.S. and overseas, counselors often tell me that the solution-focused emphasis on “doing what works” as quickly as possible is more practical than cumbersome, time-consuming approaches that don’t fit well for schools and school problems. Building on students’ strengths also appeals to counselors’ desire to empower, energize and encourage people. The fact that solution-focused counseling accommodates a variety of cultural backgrounds and life experiences is another important feature in today’s increasingly diverse world. Most people, including myself, signed up for this business to lift people up, and SFC fits nicely with this goal.

 

What prompted you to do a third edition of this book? What’s new and different in this edition?

Though many of the basic ideas and techniques of SFC have been carried over from previous editions, several aspects of my approach to SFC have changed since the previously published second edition in 2008. Research continues to clarify specific elements of effective counseling, all of which are incorporated into the new edition of Solution-Focused Counseling in Schools. These elements include the importance of building a strong counselor-client alliance and of collecting ongoing client feedback.

The third edition has new chapters on topics such as the restrictive influence of problems and practical strategies for developing “goals that matter,” as well as additional practice exercises at the end of each chapter and a widely expanded chapter on innovative ways to use solution-focused strategies in group counseling, classroom teaching, peer helping programs, parent education, consultation with parents and teachers, systems-level change and referral forms. I also included new appendices with examples of solution-focused checklists and referral forms, therapeutic letters to students of all ages, scripts for introducing client feedback tools and handy crib sheets for conducting SFC sessions.

 

What is a main takeaway you want counselors of all types, including nonschool counselors, to know about the importance of solution-focused counseling in school settings?

The main takeaway is that the ideas and techniques in this book are “value added.” A value-added technique adds value and impact to whatever it is combined with, making everything else you do with clients more effective. Examples of value-added techniques include obtaining client feedback, giving compliments, validating students’ experiences and exploring exceptions to the problem.

The beauty of these techniques is that there are no risks or downsides to using them. The worst thing that can happen is that the person does not respond and nothing changes, at which point you simply move on to something else. Even then, value-added techniques can enhance the alliance by conveying respect for people’s input, wisdom and capability. The bottom line is this: You can use the techniques in this book regardless of your theoretical orientation and regardless of whether or not you consider yourself a solution-focused practitioner.

 

You were a public school teacher and school psychologist for many years. How have you seen the role of school counselor/psychologist change since then?

I haven’t seen much of a change in the roles of most school counselors or school psychologists, especially when it comes to the small amount of time they spend in intervention-related activities such as individual and group counseling, parent/teacher consultation and schoolwide prevention/intervention programs. I am not criticizing the professionals who fill these roles, many of whom would like to spend more time on such activities. School counselors and psychologists often tell me that they are pulled in so many different directions and saddled with certain responsibilities that leave little time for counseling and other intervention-related services. Unfortunately, the situation will not change in a big way if schools continue to rely exclusively on outside professionals and agencies to provide the bulk of school-based counseling and intervention services.

 

What advice would you give to a new professional who is starting a career as a school counselor?

Find ways to stay active, involved and hopeful about your profession and the people you serve. Effective practitioners are continually engaged in professional learning and development. They also find ways to sustain their hope in the midst of the ongoing problems and challenges they face on a daily basis. I would also advise them to make sure that their job description and role includes sufficient time for counseling and intervention activities.

 

Besides your book, what resources would you recommend for school counselors who would like to learn more about solution-focused counseling?

There are many more resources on solution-focused counseling with young people and schools than there were when I wrote the book’s first edition almost 25 years ago. An Internet search of “solution-focused counseling in schools” will yield various articles and chapters. The Solution-Focused Brief Therapy Association’s website (sfbta.org) contains general information about SFBT. I also maintain a website on solution-focused and strengths-based practices in schools that has a variety of links and additional information about solution-focused practice in schools, workshop offerings on the topic and other related topics (drjohnmurphy.com).

 

 

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Solution-Focused Counseling in Schools is available from the American Counseling Association bookstore at counseling.org/publications/bookstore or by calling 800-422-2648 x 222

 

For more insights from Murphy, see these downloadable VISTAS articles from ACA:

Solution-Focused Counseling in Schools

Building School Solutions From Students Natural Resources

Student-Driven Interviewing Practical Strategies for Involving Students in School Solutions

 

Also, see ACA’s podcast with Murphy on solution-focused school counseling: bit.ly/1OSO26v

 

 

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About the author

John J. Murphy is a licensed psychologist and professor of psychology and counseling at the University of Central Arkansas. Previously, he was a public school teacher and school psychologist.

 

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Bethany Bray is a staff writer for Counseling Today. Contact her at bbray@counseling.org

 

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

 

 

Stuck in the middle

By Ann M. Ordway and Ruth O. Moore October 21, 2015

Licensed professional counselors are increasingly becoming involved in court proceedings relative to their work with families involved in high-conflict divorce, separation and custody litigation. Counseling professionals can serve in a variety of roles when working with families embroiled in divorce litigation. For example, a counselor might develop a therapeutic relationship with an individual family member, a couple or the entire family unit. These roles are typically kept distinctly separate. However, when working with high-conflict families, such roles can become easily blurred. Thus, Child-Custody_brandingcounselors can be unexpectedly swept into litigation because of misinformation, hidden agendas, the expansion of what started as a fairly simple role or even a lack of knowledge about court terminology and procedures (such as not recognizing when counselors are required to release information to the court and when they are not).

Counselors must be proactive and engage in cautious practice when interacting with high-conflict families and with court professionals. We offer counselors 10 simple guidelines to follow.

1) Be aware of ulterior motives. There is no question that individuals going through separation or divorce appropriately turn to counselors for support and guidance to get through one of life’s most challenging psychosocial events. But the possibility also exists that attorneys will refer clients to counseling for other reasons. For example, if a couple is involved in custody litigation, an attorney might refer a client to a counselor to document the client’s version of events or to set the stage for later seeking an opinion from the counselor about the client’s mental health status or ability to function as a parent. There may also be times when attorneys direct clients to bring their children to counseling in hopes of later soliciting a supporting opinion from the counselor regarding the individual’s abilities as a parent.

A counselor needs to be clear at the onset of the therapeutic relationship about why the client is there, what the client expects, what the counselor can and cannot do and whether the referral is from the client’s attorney for a specific reason. It is critical for the counselor to also know who the identified client is.

Counselors can certainly work with clients to enhance their coping skills and to effect change. If a client has a history of substance abuse, for example, proactive and voluntary involvement in counseling can demonstrate that client’s interest in and willingness to tackle a problem before being ordered to do so by a judge. Participation in counseling can also indicate effort and bolster a court’s impression that the client’s problem is under control.

However, it is important that counselors not be used to perpetuate a false impression for court purposes. Counselors cannot control the sincerity of a client’s motive, but we do not want to be complacent in a ruse to gain an advantage in court.

2) Know your role and avoid dual relationships/multiple roles. A counselor in a therapeutic role provides support for clients and empowers them to build on their existing strengths and make positive changes. In contrast, an evaluator gathers information from multiple angles and sources for the express purpose of rendering a report and recommendations to the court.

Counselors can certainly opine about the condition and progress of the client. However, counselors should not opine about the condition, progress or functionality of individuals they have not met or for whom they have limited information.

Sometimes the client, or an attorney, will ask the treating counselor to offer an opinion about specific issues such as parental fitness, abuse or domestic violence. The counselor must offer recommendations and opinions that are consistent with the counselor’s role and competency. For example, it might be fine to say that the client presents with symptoms consistent with someone who has been a victim of domestic violence. But if the counselor’s information is limited only to what the client has told the counselor, it would not be prudent to comment on the propensity of the client’s partner toward violence. Similarly, it would not be prudent to repeat the client’s statements as fact if the counselor was not present for the described events.

3) Be familiar with ethical codes, legal statutes and best practices. The 2014 ACA Code of Ethics specifically addresses issues such as informed consent and confidentiality, dual relationships, multiple roles and identifying the client. When in doubt about a situation, counselors need to always consult the ACA Code of Ethics and avail themselves of the ethical consultations made available through the American Counseling Association (call 800.347.6647 ext. 314 or email ethics@counseling.org).

It is also in the best interest of counselors to be familiar with their state laws and regulations. Some state laws include nuances that more clearly define when confidentiality must be broken, such as in cases of child abuse and neglect.

Counselors must also refrain from offering legal advice to clients, while at the same time remaining aware of laws in their jurisdictions so they can avoid guiding clients down the wrong path. Counselors should refer clients to attorneys when legal advice is needed and in the client’s best interest. One counselor encountered serious legal problems and a licensing board complaint when she suggested that a client, whom the counselor believed to be a victim of domestic violence, take the children and relocate to another country where the client’s family lived. States have specific laws regarding the removal of children from the jurisdiction. Removal of children without the permission of the court or consent from the other parent can result in criminal charges against the removing parent and a loss of custody.

4) Obtain consent and document all contact. Counselors should obtain copies of any documentation regarding custody and visitation when a separation or divorce is involved. Counselors need to ask for the most current copy of the court order and document that the copy is represented to be the most current copy. A counselor’s informed consent document should outline the expectation that all modified and updated court orders will be provided as they occur.

When there is no official documentation, counselors must keep detailed records about what they were told and by whom. Counselors working with children in divorce situations should seek consent and input from both parents whenever possible. When this is not possible, the reasons should be documented. Sometimes a court order will grant one parent sole custody of the children or sole decision-making authority. Other times one parent may state that the other parent isn’t involved because of estrangement or death. Client records need to reflect what the presenting parent has told the counselor so that the counselor will have a reasonable basis for proceeding if another parent surfaces and objects.

5) Offer support, not re-entrenchment. From a humanistic perspective, the therapeutic alliance is built upon support and unconditional positive regard for the client. However, in cases of high-conflict separation or divorce, there can be a fine line between the position that the client is 100 percent right and the estranged spouse is 100 percent wrong.

It can be difficult for two people to settle the economic and custody-based differences in their legal case when one person is cemented into a faulty belief system of entitlement or stuck in a position rooted in principle. Settlements result from the art of compromise, and positions based on principles can be expensive. In other words, clients are sometimes so concerned with winning a point that they lose sight of the big picture and end up jeopardizing more important elements of the case. Counselors sometimes do their clients a disservice by being so supportive of the client’s position that the client cannot move forward realistically through a legal system that is often more concrete in the application of the law.

6) Maintain neutrality where appropriate. This guideline pertains mostly to counselors working with children. It is easy to become invested in the parent whom the counselor sees or talks to most frequently. Hearing only one side of the story can absolutely affect the counselor’s view of the child’s experience, especially when the child has limited verbal or cognitive abilities, is not emotionally insightful or is not detail oriented.

Counselors should start with the understanding that children generally fare much better in divorce situations when they are not caught in the middle. Counselors serve the child well by supporting his or her relationship with both parents, unless there is a clear risk of harm to the child. Counselors can refer family members in need of support to other professionals to avoid conflicts of interest.

7) Do not offer an opinion of someone you have never met. It isn’t uncommon for a lawyer to ask a child’s counselor to render an opinion and recommendations regarding custody of the child or for a client’s counselor to opine regarding parental fitness and ability. However, the counselor should stick exclusively to what the counselor knows.

It is OK to speak about the counselor’s own client — with the client’s permission — to include what that client has reported, the consistency of words and affect, and impressions regarding that client. It is not wise, however, to offer comment on a parent whom the counselor has never met. Such comments would be based exclusively on what the parent who is a client has reported to the counselor. It is acceptable to state, “The client reported that her husband hit her,” but it is not advisable for the counselor to state, “Mr. Jones is an abusive man who is violent in his relationships. He should not be trusted to have custody of his son.”

8) Do not assume you can avoid court involvement. Some counselors think they can avoid court involvement by adding one or two phrases to their informed consent documents stating that they refuse to participate in court proceedings. Although there might be an argument that the client agreed to waive any right to call the counselor as a witness, a subpoena can trump that agreement. In other words, if an attorney subpoenas a counselor, the counselor will likely have to appear for a deposition or for a hearing.

The counselor can seek to have the subpoena quashed and should not release any clinical information until it is determined that the subpoena is valid and will be upheld. Best practices suggest that the counselor obtain consent from the counselor’s own client or an authorization to release information. However, even without that consent or waiver, the counselor may have to provide records or even testify.

Avoiding court begins the moment the client walks in the door. Informed consent and documentation are essential. Counselors should be trained in courtroom dynamics, testimony and legal and ethical issues even when it is the counselor’s preference to not go to court. Such measures, including ongoing communication with the client, can decrease the likelihood of having to participate in court proceedings.

9) Consult with your state licensing board, malpractice insurance carrier or attorney when necessary. If subpoenaed, consulting with an attorney before releasing records or providing testimony is wise. It is helpful for any counselor whose practice involves working with high-conflict families to have an attorney available for prompt consultation if necessary.

An attorney can review documents and guide the counselor regarding the process for balancing ethical responsibility and court involvement. Sometimes subpoenas can be quashed or suppressed. Some counselors make the mistake of responding to a threatening letter from legal counsel suggesting that the counselor must immediately make all records available. An attorney will know if the request or demand is valid in the counselor’s jurisdiction and can guide the counselor away from any ethical pitfalls associated with an incorrect response or the premature release of confidential records. Under no circumstance, however, should a subpoena simply be ignored.

10) Choose your words carefully. Wording can be everything. When asked for a report or an opinion, the counselor should confine his or her response to that which the counselor knows. Counselors should avoid supposition and assumption. It is acceptable to say, “My client stated …,” but it is not acceptable to respond as if the counselor was present or witnessed the event unless that is the case.

Simple wording can make a difference in how the counselor’s opinions or recommendations are received. When asked a question by an attorney, the counselor should listen to the question, think about it and then offer an answer that is responsive without providing more information than was requested.

Credibility is critical, and it is the counselor’s reputation (as well as the best interests of the client) on the line when the counselor renders an opinion or makes recommendations. The counselor must be able to support recommendations and opinions with facts, best practices and empirical evidence.

Conclusion

Counseling high-conflict families going through separation or divorce can present a slippery slope. The work is extremely important for the family unit and its individual members because they are dealing with an extremely challenging life event. However, cases involving the courts are stressful in even the simplest of cases. Many counselors prefer to maintain a supportive role and do not wish to do forensic (court-related) work. However, they can easily be maneuvered into the role of witness regardless of their efforts to avoid that position.

The guidelines provided in this article do not represent an exhaustive list of the professional and ethical responsibilities of counselors involved with high-conflict divorce cases. However, following these guidelines can help counselors maintain credibility, be more mindful of potential legal and ethical obligations and provide the client or family with needed emotional support. The guidelines should also remind counselors of the importance of receiving training for work with this population.

 

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

Ann M. Ordway has been an attorney for 25 years and practiced in family court for many years before entering the counseling profession. She is completing her doctorate in counselor education and supervision through Walden University. She is a distance clinical professor in the Department of Counseling and Special Populations at Lamar University in Beaumont, Texas. Contact her at aordway@lamar.edu.

Ruth O. Moore is a licensed professional counselor and national certified counselor who is a distance clinical professor at Lamar University. She has extensive experience in expert witness testimony and has published and presented widely on court process in child abuse and child custody cases. Contact her at rmoore@lamar.edu.

Letters to the editorct@counseling.org

 

Diagnosing ADHD in toddlers

By Donna M. MacDonald August 27, 2015

In 2000, Dr. Steven Hyman, then director of the National Institute of Mental Health (NIMH), made a statement for the record and publicly recognized that preschoolers can have the mental health condition of attention-deficit/hyperactivity disorder (ADHD). He made this statement even though this belief was not widely accepted at the time. He further stated that preschoolers with ADHD were _toddlersunable to interact happily and healthily with friends and family members, significantly impairing their self-esteem and the stress level of the family unit. Therefore, Hyman urged a push for more studies to be conducted on medication for children as young as age 3. (It’s important to note that Hyman is not “for” or “against” medication; he is for what is right for each individual case). He was hopeful that more studies and results would give parents of young children legitimately suffering from this disorder more treatment options.

In 2011, the American Academy of Pediatrics adjusted its guidelines for the diagnosis and treatment of ADHD to include younger children. Previously, it had “allowed” ADHD to be diagnosed in children only 6 and older, but since the push from NIMH in 2000, more research studies had in fact been conducted, and those results warranted the change to include the diagnosis and treatment of preschoolers.

Some public school preschools enroll their students at age 3 (even though most children start a bit later because of where their birthdays fall on the calendar). An ADHD diagnosis requires that the symptoms be consistently intense and frequent for a period of six months, which means that most preschoolers who legitimately have the disorder are receiving the diagnosis at the end of age 3 or the beginning of age 4. According to Dr. Demitri Papolos, a recipient of an NIMH Physician/Scientist Award whose research findings have been widely published, the latest research suggests that the age of onset for ADHD is usually prior to age 4 and can occur as early as infancy. The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) reports that ADHD symptoms will have an onset prior to age 12 and that the observation of excessive motor activity during toddlerhood is likely. However, the DSM-5 states that these young cases of ADHD can be hard to distinguish from normative behaviors.

‘Within normal limits’

Given this information, what should counselors watch for in terms of identifying possible ADHD symptoms in these very young children? It can be challenging to discern between the typical hyperactivity, impulsivity, inattention, irritability and aggression that toddlers will inevitably display and the symptoms that are actually clinically significant and indicative of the neurodevelopmental disorder of ADHD in 1- to 5-year-olds. This is because in toddlers, as the DSM-5 states, behavior and emotional expression that is considered “within normal limits” spans a very wide range. Consider, for instance, the following scenarios:

  • What if a 1-year-old bites her sister?
  • What if a 2-year-old throws a tantrum in the store when he doesn’t get the toy he wants?
  • What if a 3-year-old runs around the minivan and won’t stay in her car seat?
  • What if a 4-year-old constantly says “NO!” and won’t follow directions?
  • What if a 5-year-old can’t sit still at the dinner table?

All of these scenarios can be associated with ADHD, but they are not necessarily indicative of the child actually having ADHD because each of the examples can fall within normal limits for the age range. This does not mean that these behaviors are always acceptable, however. Therefore, some of these behaviors will need modification.

On the other hand, in some instances, parents really do need to lower their expectations of what a toddler can and should be able to do. After all, toddlers are not meant to be mini-adults or even mini-children. Therefore, it is important to remember that it’s normal for a toddler to say “no” because it means he is trying to gain a sense of independence. It’s normal for a toddler to throw a tantrum when she doesn’t get her way because of the need for immediate gratification, which is associated with an immature frontal lobe of the brain. It’s normal for a toddler to want to run, jump and climb because movement actually helps the brain develop properly and helps the toddler to feel well emotionally. Toddlers don’t have long attention spans, so sitting still should be difficult for them.

According to staff members who specialize in early intervention with children ages birth to 36 months at the U.S. Department of Health and Human Services, a child who is 12 to 15 months old should be able to hold attention to an activity for one minute. A child who is 16 to 19 months old should be able to hold attention for two to three minutes. Nearing age 2, a child should be able to attend for three to six minutes. By age 3, this attention span should increase to five to eight minutes, and by age 4, the child should be able to hold attention to one activity for eight to 10 minutes. This does not mean, however, that the child will necessarily be able to remain still while attending to the activity. It is important that clinicians and physicians have a thorough understanding of what is within normal range so that they do not misdiagnose ADHD.

As the child ages, the range of behaviors that is considered within normal limits diminishes significantly. For instance, if a 7-year-old engages in any of the scenarios listed above, such as biting another child or running around the minivan while the parent is driving, especially if this happens on a regular basis and the child is not responsive to consistent behavior modification techniques, it provides much more reason for concern for an actual mental health condition.

Indicators of ADHD in toddlers

So, what are the signs of actual ADHD in a toddler? For actual ADHD, the toddler’s behavior must showcase a pattern of chronicity, meaning demonstrating the behavior frequently and consistently for a period of at least six consecutive months and without responding to consistent behavior modification techniques. In addition, the behavior of a toddler with ADHD must be intense in nature — much more intense than a typical toddler who might showcase these symptoms occasionally.

There will also be a rule-out procedure for ADHD to ensure that the toddler’s behavior is not due to normal temperament, a medical issue or sleep disorder, the externalization of daily stressors or another mental health condition. If all these causes for the toddler’s behavior are ruled out, the following may serve as signs of ADHD in the toddler:

  • Putting self in danger on a regular basis. This action is due to the presence of novelty-seeking behaviors, sensory-seeking behaviors or impulsive behaviors. Examples include hanging over a second-story banister, jumping down an entire flight of stairs, climbing the bookcase or the drapes, or darting into the street.
  • Putting others in danger by impulsively becoming physically aggressive, such as ripping toys out of others’ hands or pushing another child off of a swing. These actions are the result of a strong need for immediate gratification.
  • Struggling to make friends and difficulty following social norms, such as taking turns while talking, sharing toys or waiting in line. Parents of young children with ADHD may notice that other parents routinely cancel play dates with them or are not heard from again after having one play date with their child.
  • Falling behind in preschool despite interventions in the classroom to help the child succeed.
  • Engaging in tantrums for extended periods of time (15-30 minutes) on a daily basis or, sometimes, several times per day. During these tantrums, the child loses all rational thought. These tantrums display cognitive, behavioral and emotional impulsivity. Many of these instances are triggered by events that are considered “minor.” Most typical toddlers would not react in this extreme manner to these events, so this type of reaction is considered “disproportionate to the event.”
  • Overreacting in a positive manner to minor events. An example is jumping from one piece of furniture to another out of excitement, yelling loudly and throwing his or her hands in the air because of getting to go to the park, even when visiting the park is an almost daily occurrence. This overreaction makes it especially difficult for the child to transition into actual participation in the desired activity because he or she struggles to calm down.

Behaviors must be measured not only in terms of developmental norms but also in proportion to the event. If an 18-month-old goes to the library for the first time, she may run, yell loudly and touch every book she can out of excitement. However, if the child is now 4 years old, has been to the library regularly and still struggles to use “quiet feet” or cannot maintain herself for the five minutes of story time, that is cause for concern. If a 3-year-old throws a tantrum for 20 minutes because the big trip to Legoland — a place the child has never been before — has been canceled, that’s more “normal” than if a 4-year-old engages in a tantrum for 20 minutes because it’s raining and he can’t go to the local pool that he visits almost every day. That reaction would be considered disproportionate to the event.

Children younger than 6 or 7 cannot process traditional talk therapy because of its abstract nature. Therefore, it is important to get the young child with ADHD involved in another form of interpersonal behavior therapy to work on self-awareness, self-management, social skills and decision-making skills. Play therapy, dance/movement therapy, art therapy, music therapy and animal-assisted therapy are examples of nontraditional therapy forms that may be especially appropriate for young children, as long as clinicians are incorporating all of the self-regulation skills necessary for a child to use age-appropriate behavior.

 

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Donna M. MacDonald is a licensed clinical professional counselor who has worked professionally with ADHD for 15 years as a teacher, YMCA director and, currently, licensed clinical therapist in a therapeutic day school. She is also the mother of 6-year-old twins who were diagnosed with ADHD at age 3. She is the author of the book Toddlers & ADHD under the pen name Donna Mac. Contact her through her website at toddlersandadhd.com.

Letters to the editor: ct@counseling.org

 

Related reading: See MacDonald’s Counseling Today article from earlier this year: The connection between ADHD, speech delays, motor skill delays, sensory processing disorders and sleep issues

 

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Empowering youth victimized by cyberbullying

By Janet Froeschle Hicks February 25, 2015

JF_HicksTechnology has changed the way adolescents bully one another. What once happened during an eight-hour school day now happens online within the home environment. This form of bullying is inescapable and occurs at all hours of the day and night. For victims, the consequences of being targeted by this behavior can range from lowered academic achievement to mental health issues such as anxiety, depression and even suicide. When assisting victims of cyberbullying, I find a combination of principles from Rudolf Dreikurs’ mistaken goals, Betty Lou Bettner and Amy Lew’s Crucial C’s, Alfred Adler’s social interest and Steve de Shazer’s solution-focused brief therapy to be helpful.

Dreikurs contended that children mistakenly seek out attention, power, revenge and inadequacy in lieu of healthy personal goals. This might explain some of the behavior associated with cyberbullying. For example, adolescents might bully one another to gain attention or power from others. The victim may then choose to perpetuate the behavior by seeking revenge or choosing a stance of inadequacy and hopelessness.

Fortunately, Bettner and Lew describe four Crucial C’s that I find helpful to positively displace a youth’s mistaken goals. These Crucial C’s consist of feeling connected, feeling courageous, feeling capable and feeling that you count (or are important). In my opinion, shifting the focus from Dreikurs’ mistaken goals of revenge, power, attention and inadequacy to those of courage, capability, connectedness and importance may change the outcome of cyberbullying from victimization to empowerment. This change of focus could alter the cycle of cyberbullying so that victims do not choose revenge and therefore avoid becoming perpetrators themselves. Additionally, victims become focused on improving internal characteristics and, in turn, enhance mental health.

Adler’s social interest may be used to further reinforce these Crucial C’s. Victimized youth who become involved in helping others demonstrate courage as part of initial engagement and experience connectedness as a result of their community involvement. Furthermore, I believe they experience a sense of counting or importance as a result of their contributions, as well as self-evidenced proof of their capabilities. As youth victimized by cyberbullying experience these Crucial C’s firsthand, they become empowered and feel more in control of their feelings and reactions. Self-efficacy and self-esteem begin to replace anxiety, depression and hopelessness.

The theoretical principles mentioned above become even more productive when combined with de Shazer’s solution-focused brief therapy techniques to assist victims of cyberbullying. Complimenting youth when they avoid mistaken goals and demonstrate positive attributes and behaviors builds a foundation on which courage can thrive. Instead of exhibiting retaliatory behaviors, the victim of cyberbullying may exhibit developmentally appropriate coping skills. According to de Shazer, complimenting involves pointing out a person’s strengths so that self-efficacy is instilled and recognized. Exception questions allow victimized youth to uncover times when they responded to difficult times without negative behaviors or emotions. This encourages a focus on what works rather than replicating self-defeating mistaken goals and behaviors. Solution-focused brief therapy feedback allows the counselor to reinforce the client’s strengths at the end of a session, connect ideas by agreeing with the client’s stance and suggest a task for the client to undertake.

In short, a synthesis of Dreikurs’ mistaken goals, Bettner and Lew’s Crucial C’s and Adler’s social interest with de Shazer’s solution-focused brief therapy techniques may empower victims of cyberbullying and improve their mental health. The case of “Elizabeth” that follows illustrates how I specifically combine these elements within a counseling session.

Case study

Elizabeth is a 14-year-old high school freshman. Her teacher referred her to the school counselor because her grades are falling and she is skipping classes. Not surprisingly, Elizabeth reveals that she is spending most of her nonschool time communicating with others through social media. It doesn’t take long for the counselor to discover that another girl is cyberbullying Elizabeth. Elizabeth indicates that her self-esteem has fallen, and she thinks about the social fallout constantly.

Because Elizabeth’s self-esteem and grades have declined, she needs to believe that she is capable of succeeding and that she has value (or that she counts). At the same time, she requires the courage to overcome feelings of inadequacy, thoughts of revenge and a desire for power and attention. The connectedness she already possesses with friends and family may help Elizabeth overcome some of the negative feelings associated with being cyberbullied.

To accomplish this in the counseling session, I use a five-step model:

1) Build rapport

2) Identify and express emotions

3) Integrate feelings and experiences

4) Develop coping strategies

5) Administer feedback

The initial use of solution-focused brief therapy may be effective in building rapport with Elizabeth and changing the overall tone of the session from a focus on the negative to a more positive position. Elizabeth needs to be genuinely complimented so that she minimizes feelings of inadequacy and refocuses on her personal strengths. Asking Elizabeth exception questions helps her to focus on instances when she has been successful. When followed by solution-focused complimenting, this also helps her to reframe the situation and begin to feel empowered.

Next, Elizabeth must identify and express the emotions she feels at home, at school and online. To accomplish this, I ask Elizabeth to describe how she feels in each setting and to associate a color with each feeling. Next, I have her draw a line using a different colored marker for each emotion on three separate pages (school, home and online). Each colored mark is labeled and discussed as a representation of an emotion she feels within that particular setting. I then use solution-focused brief therapy complimenting and exception questioning techniques to demonstrate ways in which Elizabeth is positively handling these emotions. Pointing out times when Elizabeth has handled similar emotions adequately ensures a focus on her strengths and a repetition of the Crucial C’s as demonstrated in her response behaviors.

To integrate feelings and experiences and to expand on ways that Elizabeth is demonstrating the Crucial C’s, I find it helpful to assist her with associating mistaken goals and the Crucial C’s. When shown separate index cards, each containing a written mistaken goal, Elizabeth reads the word and describes a time when she experienced each feeling. For example, Elizabeth might read the word inadequacy and say, “I feel inadequate every time that girl posts something about me.” Or Elizabeth might say, “The word revenge reminds me of the time I got even with her by telling lies about her to others.”

After Elizabeth elaborates and finishes the story, I ask her to tell me which of the Crucial C’s she needed to improve the situation. She then retells the story using the selected Crucial C. For example, Elizabeth might retell the story about revenge with a new focus on courage and connectedness. For instance, “That girl said I was ugly, but instead of making up lies about her, I logged off and texted my best friend. We talked about other things until I forgot all about it. It took courage not to get even, but because I have other friends, I was able to do it.”

Finally, I ask Elizabeth to generate short-term and long-term coping mechanisms. Exception questions help Elizabeth recognize and generate this list of ways she has previously coped in similar situations. These strategies may include creating art, journaling, playing video games, playing with pets, exercising or participating in sports, playing or listening to music, doing guided imagery, visiting with friends, talking to parents and numerous other ideas. To strengthen her long-term coping strategies, I ask Elizabeth to find a social interest activity. Suggested activities include mentoring younger children affected by cyberbullying, creating safety tips for children who surf the Internet, reading empowerment stories to younger children, reading to or visiting elderly adults, volunteering to work in community agencies and countless other possibilities. I then ask Elizabeth to contemplate these ideas, generate a list of both short-term and long-term coping strategies to use during the next week and return to the next session with social interest ideas.

At the end of the session, I incorporate de Shazer’s solution-focused brief therapy feedback technique. I compliment Elizabeth once again so her strengths are evident to her as she leaves the session. For example, I might say, “I recognize the courage it took to share all of this with me this week. I think that shows you have strengths to help you get through this.” Then I might add, “I agree that you need to feel better about yourself. Over the next week, I suggest using the short- and long-term coping strategies you listed as well as finding a project to help others while helping yourself.” To conclude, I ask Elizabeth to report on her success at the next session.

Subsequent sessions focus on self-reported improvement and implementing social interest activities. There is also continued focus on implementing the Crucial C’s in lieu of mistaken goals. Solution-focused brief therapy techniques, including complimenting, exception questions and feedback, are used throughout all sessions to continue reinforcing Elizabeth’s strengths. Finally, I incorporate Internet and online safety and social media trainings for Elizabeth and educate her parents on what Elizabeth is experiencing all day, every day online.

Why include parents?

Parents are included in future sessions for several reasons. First, upon hearing about cyberbullying, many parents fear the Internet and insist that their children avoid all technology. Although this may be an effective short-term solution, I do not believe it helps long term. Eventually, youth find themselves required or tempted to use the Internet for employment, homework or socialization.

As a result, I teach Internet and online safety skills both to parents and youth. These safety tips provide education about privacy and restraint when posting online, decrease fear and allow youth to continue using the Internet provided that their parents are involved in Internet communications. Youth and parents must understand the importance of keeping specific personal information private as it relates to the long-term and worldwide reach of the Internet. Once parents understand how to use social media appropriately, they have an opportunity to become role models for the proper use of technology. Learning strategies to avoid harm while using the Internet may be an important mechanism for personal empowerment for both victims of cyberbullying and their parents.

Another reason counselors should involve parents is related to the mistaken goals discussed earlier. Initially, parents often respond to their child’s victimization with inappropriate feelings of attention, Branding-Box-Cyberbullyrevenge, inadequacy and power. These feelings could result in parental behaviors that perpetuate bullying rather than improving the situation. For example, some parents initially respond to knowledge that their child is being cyberbullied with feelings of revenge. These parents may confront the bully or the bully’s parents and unknowingly increase, rather than decrease, their child’s victimization.

I teach parents to first empathize and communicate with their child. It is important that any parental response to bullying first be discussed with the child. If nurtured, the bond between parent and child may become the greatest protective element for youth who have been cyberbullied.

Conclusion

As Elizabeth experiences the Crucial C’s firsthand through social interest, feels secure in the bond with her parents and focuses on her strengths, she begins to feel empowered rather than victimized. Internet safety tips that illustrate the importance of privacy and restraint when posting online further demonstrate to Elizabeth that she possesses courage and has control over life events. Eventually, Elizabeth is able to focus on her own value rather than on the unhealthy stigma perpetuated by others.

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

Janet Froeschle Hicks is an associate professor of counselor education and chair of the Educational Psychology & Leadership Department at Texas Tech University. She is both a licensed professional counselor and a certified school counselor in Texas. Contact her at janet.froeschle@ttu.edu.

Charles R. Crews, associate professor of counselor education at Texas Tech University, also contributed to this article.

Letters to the editor: ct@counseling.org

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Responding to the rise in self-injury among youth

By Brent G. Richardson & Kendra A. Surmitis October 23, 2014

The prevalence of nonsuicidal self-injury (NSSI) among adolescents and young adults has rapidly and significantly increased in recent years, leading mental health professionals and researchers to describe its pervasiveness as epidemic. By definition, a person does not engage in NSSI with intent Photo of authors Brent Richardson and Kendra Surmitisto die. Rather, NSSI is a means of regulating emotions, relieving tensions, managing dissociative symptoms and influencing others. It is critical that counselors working with youth gain an understanding of NSSI and recognize its prevalence within the adolescent population.

There is growing evidence that many teenagers who engage in NSSI have been influenced by their peers. In 1985, Barent Walsh and Paul Rosen defined self-injury contagion in two ways:

1) When acts of self-injury occur among two or more persons within the same group within a 24-hour period

2) When acts of self-injury occur within a group of statistically significant clusters or bursts

The primary focus of this article is to identify environments that present a high risk for self-injury contagion and to suggest opportunities for counselors to minimize and prevent contagion when working with adolescents.

Benefits and pitfalls of group work

Many programs designed to treat adolescents who self-injure include group therapy as an essential ingredient in the treatment milieu. S.A.F.E. (Self Abuse Finally Ends) Alternatives, founded in 1985 by Karen Conterio and Wendy Lader, was the first treatment facility designed specifically for people who self-injure. Since its inception, clinicians at S.A.F.E. Alternatives have used group therapy as a central feature of its treatment programs. Dialectical behavior therapy (DBT), which combines individual therapy, group skills training and family education, has emerged as one of the most effective treatments for adolescents who are suicidal and/or self-injure. Many of the key skills needed to reduce self-injurious behaviors (for example, emotional regulation, distress tolerance and interpersonal communication skills) are learned and practiced in group therapy. Solution-focused therapist Matthew Selekman recently developed a nine-session Stress-Busters’ Leadership Group geared specifically toward adolescents who engage in self-destructive behaviors. The group is applicable in both school and community settings. While these group approaches (S.A.F.E. Alternatives, DBT and Stress-Busters) have several differences, it is important to note that each is largely didactic, highly structured and skill-based.

Group work is appealing both to adolescents and counselors for a number of reasons. For logistical and developmental reasons, group homes, residential facilities and hospitals typically utilize various forms of group work as their primary mode of treatment. Groups are more efficient and cost-effective than individual approaches because they enable counselors to work with more clients. In addition, group work tends to be a better developmental fit for adolescents than individual therapy, and adolescents often prefer it because a significant amount of social learning occurs in the context of formal and informal groups (for example, family group, classroom group, social group and sports teams).

Youth who self-injure tend to feel isolated and disconnected. Although individual counselors can inform youth that they are not alone, the group process allows them to experience a sense of universality with their peers, while learning from others who are at different stages in the recovery process. By assisting and supporting others, members begin to see themselves in a different light. One of the most effective ways to boost a youth’s self-esteem and self-confidence is to structure situations in which he or she can help others and feel altruistic.

Despite the potential benefits of using groups as a component in treating those who self-injure, there are also possible pitfalls that could disrupt the process or even increase self-injurious behaviors. Walsh, author of Treating Self-Injury, says counselors should be mindful that anytime individuals who self-injure are treated in groups, there is an increased risk for a contagion effect. In addition, he warns that groups that are largely cathartic in nature — wherein youth are encouraged to openly express their emotions and share traumatic experiences — are often counterproductive with this population. These types of groups can increase the risk of contagion because open discussion of self-injury antecedents, behaviors and consequences can be exceptionally triggering for some young clients.

Many clinicians and researchers assert that group leaders should structure activities that focus on empowerment and replacement or coping skills training, while prohibiting detailed discussion of self-injury. This can be challenging for counselors because sharing and hearing details about self-injury can be so alluring for both counselors and group members. Adolescent clients may view group therapy as an opportunity to compare wounds and share stories. These disclosures should be severely limited or prohibited from the onset, however. Counselors may want to acknowledge that discussing self-injury in great detail may be important but emphasize that those details should be shared in individual therapy rather than with group members.   

In summary, NSSI groups are most likely to be effective if:

1) Group leaders have significant training and understanding of treating self-injury and managing contagion

2) Membership is closed to enhance cohesion and trust

3) The group is governed by strict rules prohibiting the discussion of details of self-injury and the sharing of wounds or scars in the group

4) As with DBT groups, the sessions are highly structured, didactic and focus on teaching new skills and behaviors (for example, emotional regulation, mindfulness, self-soothing, distress tolerance and exercise) to help reduce further incidents of self-injury

Benefits and pitfalls of residential facilities

Similar to treatment in group therapy, clinicians who work with youth in residential treatment can be effective in counteracting self-injury, provided they follow the proper precautions.

The residential population is likely at higher risk for contagion due to peer influence and the prevalence of severe psychopathology such as eating disorders and issues with affective regulation. In fact, a number of researchers have observed that NSSI occurs in significant clusters in residential settings, including community-based group homes, special education boarding schools, juvenile detention facilities and psychiatric inpatient settings. Recognizing the potential for contagion in a residential population allows for appropriate precautions when determining the benefits of residential treatment on a case-by-case basis, and it can aid in the appropriate response to NSSI.

Several studies have found that self-injurious behaviors often increase for adolescents, regardless of Photo of self-injury wounds on armwhether they have a prior history of self-harm, during residential treatment. Clinical settings that feature multiple youth living together who exhibit emotional dysregulation can aggravate dysfunctional behaviors, including NSSI. Consequently, the increased likelihood of exposure to self-injury in a residential facility leads to the question of whether the benefits of inpatient care are worth the potential risks associated with contagion.

Despite concern for social contagion, several arguments can be made in favor of choosing residential treatment for NSSI. For example, cases that include high-risk behaviors such as clinically significant disordered eating require structured, intensive treatment. In similar circumstances, placement in a residential facility may be warranted, even if nonresidential treatment may pose less risk of self-injury contagion.

The first step in response to the risk of social contagion is making the appropriate referral to residential care on an individual client basis, while avoiding unnecessary hospitalization. Within the residential setting, precautions guide clinicians toward the appropriate response to NSSI. These responses include educating the individual client, confronting triggers of social contagion and using encouragement to motivate youth to build and share healthy coping skills.   

Subsequently, many of the challenges and recommendations for counselors who work in residential facilities are similar to those provided for group counselors. Although communicating with peers in a communal environment is beneficial for those who feel isolated and may benefit from peer support, mental health counselors are advised to educate residents on the negative effects of sharing stories of self-injury. These clients should instead be instructed to share stories of healing and healthy coping behaviors. 

Benefits and pitfalls of websites and message boards

Although the Internet is a potentially valuable source of support and information for self-injurers, various websites can also be breeding grounds for social contagion. Approximately 93 percent of American youth ages 12 to 17 use the Internet, and nearly two-thirds of adolescent Internet users go online daily. These numbers are growing every day. In the past decade, the number of websites intended for or about people who self-injure has increased. Research conducted in 2007 by Janis Whitlock, Wendy Lader and Karen Conterio revealed there were more than 500 message boards focused on self-injury. These researchers also observed the parallel between the increase in self-injury websites and the growth in self-injury awareness in society. Internet message boards provide a potent medium for bringing together adolescents who self-injure.

These self-injury websites and message boards offer a number of potential benefits. The Internet may have particular relevance and appeal for adolescents who are socially avoidant or feel marginalized. These youth may feel extreme relief upon finally being able to make meaningful connections with individuals who share similar concerns and experiences. The anonymity of these sites might also encourage youths to share more frequent and truthful disclosures about their feelings and behaviors. Positive peer pressure is another potential benefit. As is the case in group counseling, these adolescents might more readily accept online feedback from peers that encourages them to practice safer, more productive ways of expressing their emotions.

Thus, it is important that counselors not minimize the perceived value that these sites have for young clients who self-injure. Though social scientists and mental health professionals often focus on the potential harm of these discussion groups, adolescents who use them tend to self-report positive experiences as a result of their participation. For example, in one survey of self-harm discussion group members, Craig Murray and Jezz Fox found that the majority of respondents reported having reduced the frequency and severity of their self-injurious behaviors. The respondents attributed this largely to the support and guidance they found online.

Whitlock and her colleagues were some of the first researchers to study the content of self-injury message boards to better understand their role in sharing information about self-injurious practices and influencing help-seeking behaviors. These researchers found that the most common type of exchange on the message boards involved providing informal support to other posters through comments such as “We’re glad you’ve come here” and “Just relax and try to breathe deeply and slowly.”

However, in addition to the supportive communication found on NSSI-related sites, researchers also found dangerous messages. While 44 percent of all help-seeking posts presented favorable attitudes toward seeking mental health treatment, approximately 20 percent of the posts discouraged individuals from seeking treatment and/or voiced negative views about therapy. There was also considerable discussion about better ways to conceal scars and maintain secrecy.

These researchers warned that self-injury message boards expose vulnerable youth to a normalizing environment of encouragement for self-injury and hold the potential for fueling social contagion. On several sites, members shared new and often more dangerous techniques and instruments for cutting and even offered links to sites where self-injury paraphernalia could be purchased. Sites that feature graphic depictions of self-injury, including many videos on YouTube, can be highly suggestive or triggering to other self-injurious participants. Unfortunately, those who self-injure can become better at self-injury by learning from others they meet online. Some posters use chat rooms to coerce others, model self-destructive behaviors, compete with others and discourage others from stopping their self-injurious behaviors or seeking help.

As is evident, self-injury websites and message boards are helpful for some and counterproductive for others. Regardless, this needs to be an area of therapeutic inquiry. In fact, the popularity of the Internet among adolescents presents a crucial argument for assessment of Internet use in general, as well as specific assessment of Internet exposure to self-injury. Mental health professionals should therefore educate themselves about various websites for self-injurers (some recommended sites are included in the next section).

Whitlock and her fellow researchers suggested that clinicians maintain a curious, neutral, nonjudgmental tone when asking questions such as the following:

  • How comfortable do you feel hearing stories from others who self-injure?
  • Have you shared your own story? How did you feel?
  • What do you like most about having friends whom you really know only through the Internet?
  • How honest are you when you share information on the Internet? (Do you minimize or tend to embellish?)
  • Do you ever take advice from Internet friends? If so, can you provide examples of advice that you used?

Some NSSI sites have minimal or no monitoring for potentially dangerous content. If there are moderators, they typically have minimal or no training in mental health. With certain clients, counselors might assess that it is best to be direct in encouraging or discouraging particular sites or interactive behaviors. Counselors can clarify concerns about why some sites might be traumatic or triggering and therefore countertherapeutic. These direct suggestions will likely be more fruitful with adolescents who have entered counseling voluntarily, begun to develop a therapeutic relationship with the counselor and voiced a desire to stop or reduce self-injury.

Summary recommendations

In this article, several mediums have been identified as environments at high risk for social contagion of NSSI — namely group treatment, residential facilities and social media. Key considerations for the prevention of social contagion were identified. These include:

  • Developing a clinical understanding of social contagion and its significant impact on the adolescent population through training and further research
  • Working with clients who engage in NSSI to develop awareness of appropriate environments to discuss their self-injury stories, such as individual therapy sessions
  • Asking clients who self-injure to cover up scars, wounds and bandages that can be triggering
  • Prohibiting graphic detail of NSSI at the onset of group therapy
  • Incorporating strength-based strategies that encourage healthy coping behaviors in treatment
  • Assessing client Internet use, with specific attention paid to exposure to self-injury imagery
  • Determining the appropriate level of treatment and avoiding unnecessary hospitalizations that may invoke NSSI in vulnerable clients
  • Instructing clients to share stories of healing and healthy coping behaviors to decrease the opportunity for contagion, while inspiring altruistic motives in a group environment

Furthermore, the role of mental health counselors working with youth engaging in NSSI extends past the therapeutic relationship encountered in treatment to the family system and school setting to which the child is connected. Providing appropriate referrals to information for concerned individuals in the child’s life, such as parents and other caretakers, is an important action in attending to NSSI and contagion among peers. The following websites provide helpful information grounded in clinical research and professional standards.

Empowering family members and other members of the client’s care system to understand self-injury will help them to comprehend the messages sent by the child who is engaging in the behavior, while promoting an atmosphere of awareness to counteract opportunities for contagion. As a provider of information, it is crucial that the counselor is clear when it comes to appropriate Internet material, such as empirically validated information for families, and the potential misinformation provided by sites containing blogs and graphic imagery. The prevention of contagion begins with understanding NSSI in youth and empowering the people in their lives who also share in the opportunity to preclude self-injury among adolescents.

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This article was adapted from a previous article published in the American Mental Health Counselors Association’s Journal of Mental Health Counseling.

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

Brent G. Richardson is chair of the Department of Counseling at Xavier University in Cincinnati. Contact him at richardb@xavier.edu.

Kendra A. Surmitis is an assistant professor of counseling in the Department of Educational Psychology at Northern Arizona University. Contact her at kendra.surmitis@nau.edu.

Letters to the editor: ct@counseling.org

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