Tag Archives: school counselors audience

Understanding the connection between nutrition and mental health

By Robika Modak Mylroie and Rachael Ammons Whitaker January 17, 2018

In recent years, obesity has seized the attention of the medical field and the media. Now our schools are starting to recognize the impact of obesity on mental health. The United States is known internationally for its larger plate sizes, big portions and supersized meals in restaurants. However, we are also witnessing the beginnings of a cultural shift that encourages body acceptance and pushing back from an ideal body type.

At the same time, it may also seem that our society has become obsessed with healthier food options. But do we really understand nutrition? When we see terms and phrases in grocery stores such as organic, humane, low carb, high protein, non-GMO, no artificial coloring/preservatives and natural, it can be overwhelming. Some of these terms can be misleading or confusing. Our society is overmarketed with food slang and undereducated on what food labels mean to nutrition.

School and mental health counselors should be asking themselves how physical health and body acceptance intersect with weight, body mass index (BMI) and mental health. What if a person is deemed to be at an unhealthy body weight but is genuinely OK with his or her body? Conversely, what if this person is not happy with his or her body yet is considered healthy? When it comes to these body issues in children, at what point do school counselors intervene? How do we begin to support childhood social and emotional concerns surrounding nutrition without shining a light on those children who might be in a fragile stage related to their body awareness and image? How do we teach families and school employees to use language that promotes positive body image?

Although most medical journals openly discuss pediatric obesity as a major public health concern, they continually fail to address how to effectively combat such issues. The same statement applies with counselors. We know that childhood weight is a concern, but are we doing enough within our schools? Brain studies show that nutrition plays a role in learning, concentration and mental health in general, so why is it so hard for us to connect the dots?

Let’s explore the disconnect between childhood obesity, nutrition and mental health, and how we, as counselors, can support child nutrition in school settings. Can making the connection between nutrition and social-emotional needs move counselors to collaborate more effectively with other professionals? Counselors should care about what we are feeding our youth during school hours because it impacts our profession directly.

There also needs to be an awareness among parents and caregivers that nutrition is important not only in the school but at home. One of the issues that school counselors face is that not all parents and caregivers are supportive. Even if they are supportive, they may not possess the means to buy healthier food for the home or to prepare meals consistently. Preparation takes time, and not all families have that time to devote. Socioeconomic status, family makeup and genetic issues can also contribute to childhood weight and nutrition levels. For instance, there may be a lack of food in the house because the family cannot afford it, or there may be foods that are high in unhealthy fats and sugar.

Education is key to awareness, but this is difficult when we as counselors are not advocating for changes in school nutrition. We need to educate ourselves and make a connection in our profession between nutrition and mental health.

What we know

Childhood obesity is not a new concern in the United States. Many articles have been published on the health concerns of children who are overweight or obese. Michelle Obama’s “Let’s Move!” campaign brought national attention to the issue. During an open discussion this past spring, the former first lady said, “You have to stop and think, why don’t you want our kids to have good food at school?” During her time as first lady, Obama also hosted the School Counselor of the Year national recognition ceremony at the White House. This begs the question: Why have counselors, and, specifically, professional school counselors, not taken action on this issue?

Unfortunately, if the first lady struggled to implement this agenda, it stands to reason that it might be equally difficult for school counselors to get a foot in the door. Because of the disconnect between counseling and nutrition, it might even seem odd to some people that school counselors should get involved at all. As mentioned earlier, however, there is actually a deep connection between the two. Researchers have shown that poor diet not only leads to physical health problems but also affects brain functioning. Brain studies have shown that what people eat affects not only the social-emotional realm but also academic performance.

In March 2017, Laurie Meyers wrote a cover story for Counseling Today titled “When brain meets body” that discussed the connection between physical and mental health. More specifically, it delved into how thoughts can cause changes in the regulation of cortisol, which can then affect our clients’ physical health. This physical heath-mental health connection is emphasized in the mental health community but not as often in the school community and hardly at all in the medical community.

Why this research matters to us

The World Health Organization’s obesity map shows that as a whole, more than 30 percent of the U.S. population is obese. The Centers for Disease Control and Prevention (CDC) reported that 35 percent or more of adults in Mississippi, Alabama, West Virginia, Louisiana and Arkansas were obese. The CDC also noted that there was no state in the country with an obesity percentage of less than 20 percent among adults.

Mississippi tends consistently to be near the top of the charts for adult and childhood obesity, which is what sparked our interest in pursuing research in this area (both authors are from Mississippi). One question we asked is why a state such as Mississippi, which is rich in farmland and has an abundance of crops and fresh produce, has a prevalence of obese children. Our state should have abundant nutritional food available for families, including for those of low socioeconomic status. Lack of education and what people can afford likely have some connection to obesity rates in Mississippi. Statistics show that education and salary levels are highest in those states with lower obesity percentages. Mississippi ranks last in education statistics among the 50 states.

Healthy food consumption should not be dependent on social status. It should be affordable to all. However, many foods that are healthy and easy to prepare are also the most expensive. According to the website TalkPoverty.org, 20.8 percent of people in Mississippi live below the poverty line. Schools in this state, and in many of the other states identified as “obese and overweight,” may not be able to afford these healthier options in bulk.

This raises other questions. What can we do differently to secure healthier food access in our schools for reasonable prices? How do we partner with local farmers to provide more nutritious foods or to demand that our schools contract with better food providers? Healthy breakfasts, lunches and snacks during educational hours should not be contingent on whether a child has a homemade lunch or went through the cafeteria line.

The connection for Robika

Working as a school counselor in rural Mississippi, I noticed that a disconnect existed between the medical field’s information on physical health and the knowledge of mental health within the schools. I saw many children who would likely be classified as overweight or obese, and I saw a lot of students who were unhappy about their weight. I often consulted with the school nutritionist and nurse in these instances. With these particular students, I also noticed the prevalence of several issues that extended beyond academics to socioemotional problems, including bullying, self-esteem issues and anxiety. This observation sparked my curiosity about the possible connection among these different variables.

I wrote my dissertation about the connection between childhood obesity and personal, social and academic issues. Although I didn’t find a statistically significant connection (probably because of limitations in research), I did identify individual connections in my sample between self-esteem and interpersonal relationship satisfaction. This led my wanting to know more and wanting to continue this research and advocacy within the schools.

The problem was — and continues to be — that obesity is a difficult topic for schools to address. Obesity is a buzzword that is sometimes considered offensive. It was difficult getting parents and caregivers to agree to let me weigh their children.

As Rachael and I began collaborating on this topic, questions started forming: Why are school counselors not more involved? BMI doesn’t provide a fair reading of weight for different ethnicities, so why are we using it to define weight? What other way can we measure weight to incorporate multicultural, nutritional and genetic considerations? How can we fill in this gap among the medical, school nutrition and mental health worlds? Would school counselors be comfortable talking about this topic?

These questions continue to drive us as we move into more detailed research and advocate for school counselors and for our students.

The connection for Rachael

During my doctoral research classes, a professor said to me, “Rachael, bring in any research that sparks curiosity.” This simple statement opened a wormhole of personal curiosity, followed by fear and then drastic dietary changes. Becoming a good consumer of research resulted in me experiencing emotional ups and downs, especially when I decided to read more about Food and Drug Administration food protocol, particularly around animal products.

This launched my personal pursuit of knowledge surrounding nutrition. However, the real lightbulb moment took place when a direct correlation was drawn between some of my food intake and my autoimmune disease that I had been medicating for years. It was also around this time that Robika asked me to help collect data for her dissertation. Her research lit a fire in me to implore my friends, family members and students to care more about what they were putting into their bodies. Now, as the research advances, Robika and I hope that we can support counselors in K-12 settings in getting involved in school food purchases and menu planning.

What we can do about the knowledge gap

A lack of information exists concerning how school counselors can promote wellness and nutrition in terms of social and emotional health. Researchers for HealthCorps, an advocacy group that incorporates wellness education into schools, based their study on three domains: nutrition, physical activity and mental health. However, the term mental health was a misnomer because it did not encompass all aspects of mental health. Instead, it was essentially defined as mental resilience. In addition, no counselor was included on the study’s development team, which consisted of dietitians, nutritionists, integrative human physiologists and other health care professionals.

Through our own research, we believe that we are on the path to helping school counselors promote wellness, healthy weight and mental health through prevention and intervention methods with students and their families and within the school itself. Our long-term goal is to make connections between the brain, childhood weight and mental health, and then to use this information to help school counselors collaborate with school nutritionists and communities to create better lifestyle choices and, in turn, promote socioemotional wellness. We decided that we needed to start with school counselors themselves to get a better understanding of how comfortable they are talking about these issues, and especially childhood obesity. Again, the word obesity brings up a number of issues for many people.

We have received really wonderful feedback when presenting on this topic. Not a lot of counseling research has been done in this area. As a result, we have found that many counseling professionals are very interested and agree that it needs to be researched more thoroughly. Unfortunately, presenting this line of research to the schools has been difficult. Parents tend to keep their children from participating in research related to obesity and nutrition, and school boards, faculty members and school staff often have a difficult time with it too. Realizing that school counselors may not feel comfortable using the term childhood obesity, we have since changed this term to childhood weight. In this case, we can also talk about the opposite spectrum of obesity, which includes disorders such as anorexia nervosa and bulimia.

Another aspect of what we are attempting to do is to place these terms within the context of ethnicity, age and gender. In our initial research, we measured BMI because this was the only option for calculating obesity. However, we know that some ethnicities may be more susceptible to qualifying as overweight or obese even though they are of normal or healthy weight. Another example is that athletes who are larger and more muscular are not necessarily overweight or obese, but their muscle mass may tip the scales toward them being classified as overweight.

As counselors, we have to be aware of the demographics of our communities. This is not a new concept of course, but we can start making little ripples to address a larger problem, especially in the schools. In some towns, nutritious foods are not available or affordable. High-calorie, high-fat foods are more readily available and come at lower prices. Once the cycle of eating high-calorie foods begins, it can be difficult to change it. Children who are taught about nutritious foods may mention this to their parents, but the parents may ignore the request because they cannot afford these foods or because the foods do not sound appetizing. Other parents may work multiple jobs and not have time to make meals for their families. Some families have to rely on their older children to make dinners.

Home life aside, however, schools need to work to have healthy options. Some schools will present the choice between a baked meal and a fried meal. Many students will opt for the fried meal. Although choices are important, we propose that children be presented with more healthy options. Countries around the world have lunches made from scratch that include vegetables, seafood, whole wheat breads, fruits (rather than sugary syrup) and nonprocessed meats and cheeses.

Children should also be educated about their food. This empowers them to make healthy choices based on their own knowledge. They can even be involved in planting vegetable gardens at school or preparing meals at home.

However, there seems to be no connection or collaboration between the different fields of research, even though there are several areas of knowledge that intersect.

We believe there are ways that these three knowledge bases can work together and help each other. The image on page 52 [of the print version of this article, ] shows our proposed Integrative Collaboration Childhood Weight Model, which is where our research will go next. We want to bridge the gap and highlight what the features of each area are, as well as bring them together to create a richer research model.

Our hope is to first understand school counselors’ comfort level when discussing the issue of childhood weight. We also want an idea of their understanding of the connection between childhood weight and socioemotional and academic issues. We need to know what kinds of community, caregiver and school support school counselors receive. Do they already collaborate with the other faculty and staff in the school? If so, is this on a regular basis?

Future goals include creating prevention and intervention methods and materials that will address nutrition and socioemotional wellness in conjunction with other staff in the school district. Working as a team is more likely to result in better overall outcomes. Healthier children can mean healthier adults. So, let’s be willing to talk about the connection between food and mental health.

Potential interventions, prevention methods

Given that not a lot of research has been conducted in this area, school counselors are somewhat at a loss for potential interventions for childhood obesity. Children who are overweight or obese may come to the school counselor for issues such as self-esteem, a lack of confidence or bullying (either being the target of bullying or engaging in bullying themselves). However, we cannot assume that their weight is the reason for these issues unless the child mentions it as a cause. School counselors cannot target children who are overweight or obese for individual counseling.

Although interventions can be put into place by the school counselor for the specific issues mentioned (self-esteem, confidence, bullying), we believe that prevention methods may have the most impact for all children when it comes to childhood weight. Classroom guidance lessons focused on nutrition, wellness and self-care can be part of the comprehensive school counseling program. We also want to again emphasize the potential impact of collaborating with other school staff such as school nurses, school nutritionists and physical education teachers. Providing wellness interventions for both physical wellness and mental wellness is also likely to have a greater impact on students. Teaching these methods of self-care not only helps the whole child but also gives students the tools to continue healthy living and wellness practices across the life span.

An activity that might serve a dual purpose is horticulture therapy, in which children create sustainable gardens while also working with the earth as a form of healing. Children can learn how to grow vegetables and fruits and better understand their nutritional value even as they also grow their personal and social skills. Some children may even want to grow their own gardens at home.

Parent/caregiver involvement has been shown time and time again to be related to the success of the child. School counselors and nutritionists could present workshops for parents and caregivers focused on how they can make nutritious meals for their kids and even with their kids. Information on meals and snacks that are inexpensive but also better for the family can also be shared. Teaching parents about the value of nutrition and mental health should also be emphasized. Another area of emphasis might be teaching parents and caregivers how to engage in positive body language. Parents and caregivers are models for their children, and if they speak negatively about their bodies, then their children are likely to copy that negative self-talk.

 

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

Robika Modak Mylroie is a distance clinical professor in the Department of Counseling and Special Populations at Lamar University. Her experience consists of working in the clinical setting before becoming a school counselor. Her current research includes childhood weight, trauma and animal-assisted therapy. Contact her at rmylroie@lamar.edu.

Rachael Ammons Whitaker is the program director for the clinical mental health and school counseling programs at the University of Houston. She worked as a behavioral therapist, behavioral interventionist supervisor and school counselor before pursuing counselor education at the university level. Her current research includes understanding and advocating for intersex children and the impact of childhood weight. Contact her at rachaelammons@yahoo.com.

Letters to the editor: ct@counseling.org

 

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

Counseling students with DACA/undocumented immigration status

By Elizabeth Holbrook December 28, 2017

I was 15 years into my career as a professional school counselor when I met a young man who opened my eyes to the life of navigating the education system as a student with undocumented citizenship status. I was working in an upper-middle-class suburban high school in South Texas. This college student, who had recently graduated from our high school, spoke to our counseling staff about his experiences as a high school student with undocumented status and how Deferred Action for Childhood Arrivals (DACA) changed his life.

Ranked in the top 15 percent of his graduating class, with strong SAT scores and extracurricular involvement, he was a strong admissions candidate who also had scholarship potential. Yet, he thought his immigration status made pursuing a college degree impossible.

He kept his immigration status a secret from educators, including his counselor, until his senior year of high school, when he “came out” (his words) to a teacher he trusted. He feared exposure for himself and his family, social stigma with peers and even possible deportation. He sought DACA soon after it became available in 2012. He got a Social Security number, a work permit and a driver’s license. Most importantly, he experienced some relief from the burden of carrying a secret that had eaten at him since his mother brought him and his sister to the United States when fleeing an abusive marriage.

His former counselor asked him to come speak to our counseling staff because she felt she had failed him due to her lack of information and our counseling staff’s lack of communicating the safety zone of the counseling office. After he spoke, I came to realize that a hidden, underserved student population existed in many schools. His story inspired my pursuit of this topic both for my dissertation and for professional growth as a counselor.

As I explored this topic, it became apparent that many educators did not know how best to serve students with undocumented or DACA immigration status. Additionally, I learned that broaching the topic produced reactions ranging from knowledgeable support to embarrassed ignorance to xenophobic revelations. I chose to put this research interest into practice to gain better insight.

I have interviewed students with DACA/undocumented immigration status for my dissertation, volunteered with advocacy organizations, led counseling groups for high school students and presented about this topic in conferences throughout the United States (including at the 2017 American Counseling Association Conference in San Francisco). It is from this perspective that I offer these suggestions to my fellow counselors in high school and college settings.

  • Reflect on your legal and ethical obligations as a counselor. Be aware that the U.S. Supreme Court decision Plyler v. Doe (1982) ruled that students in K-12 public education settings cannot be denied access to free schooling based on immigration status. This does not extend into postsecondary education access. Those working at any level of education or in nonprofit organizations should know that Title IX (1964) prohibits discrimination based on race, color or national origin for organizations that receive federal funds. To not assist students with DACA/undocumented status could be defined as discrimination based on national origin, but this is not clearly defined.

Counselors have ethical obligations not to condone discrimination due to immigration status (see the 2014 ACA Code of Ethics, Standard C.5.). As judicial, legislative and executive actions continue to change, counselors might need to prepare for how their ethical obligations could collide with new laws. Consider how handling records, explaining/maintaining confidentiality and protecting clients may need to change.

  • Learn the unique steps and pitfalls involved in these students’ paths to college and career access. Counselors need to know that getting In-State Residential Tuition (ISRT) is a state-by-state decision. At this time, many students with DACA/undocumented status can get the same tuition rates as their citizen peers based on residency, not citizenship. Students with DACA/undocumented status do not get access to federal student financial aid via the Free Application for Federal Student Aid (FAFSA). Sometimes, however, students with DACA status mistakenly file for FAFSA because they have been issued a Social Security number.

Also keep in mind that most DACA recipients are college age or in the workforce. At every presentation I have conducted, I have been approached by counselors or teachers with DACA status. That means that you might have co-workers affected by the DACA decision. Most high school students did not qualify for DACA due to their entry date to the United States. With DACA ending, the number of students with undocumented status appears to be increasing.

  • Understand the emotional struggles associated with DACA/undocumented status. These students are part of the first generation of their families to go to college, which can be overwhelming in itself. But in addition, they can also harbor reasonable fears associated with their immigration status. Most come from mixed-status families and fear deportation for themselves or their family members. Parents may have instilled in their children the need to keep the family secret.

Those with DACA status may regret having exposed their identity to the government, and they now live with certain deadlines regarding their protection from deportation. Those who did not seek DACA status may regret not joining a group that may get some answers to this predicament. Facilitate empowerment by connecting these students with postsecondary mentors and support organizations that foster their agency.

  • Be aware of how current public policies affect these students personally. According to Harvard professor Roberto Gonzales, these policies create a state of liminality (betweenness) for these students. Not having citizenship status and not having a path to citizenship in their home country puts them between countries in a manner unique to their situation. The lack of certainty is a constant; long-term plans can seem useless. Supreme Court decisions can be overturned as part of a multitiered process, executive actions can be issued swiftly, and bills going through Congress can stall. Counselors can help students understand these processes.

If you work on a college campus, you have probably seen petitions, rallies and information sessions. Many of these students are seeking support, but they may get discouraged as they see the spotlight move to other current issues. They are practicing acts that citizens employ regularly, but they do not have the protection of citizenship. Going public is risky and can create emotional responses. In addition, citizenship can be taken for granted by those who have it. For those who do not have it, perceived apathy on the part of citizens can be offensive and further trigger emotional responses.

When I began my learning journey about students with DACA/undocumented status, I had no idea it would become a highly charged political issue. In light of recent events, I felt an obligation to share with the counseling community what I have learned. I also want to thank the students, educators and community service members who enlightened me about this hidden student population.

 

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Elizabeth Holbrook has more than 20 years of experience counseling in K-12 public schools. She is currently a professional school counselor in Northside Independent School District in San Antonio, Texas. She is also an adjunct professor at Our Lady of the Lake University, where she teaches graduate-level students in the school counseling program. Her dissertation, “Exploring the experiences of students of Mexican descent with Deferred Action for Childhood Arrivals status,” can be found at athenaeum.uiw.edu/uiw_etds/22/. Contact her at Elizabeth.holbrook@nisd.net.

 

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Related reading, from the Counseling Today archives:  “Mental health implications of undocumented immigrant status

 

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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.

U.S. student-to-school counselor ratio shows slight improvement

By Bethany Bray October 20, 2017

On average, there is one school counselor for every 482 K-12 public school students in the U.S. This number has decreased slightly from the previous year’s average of 491-to-1.

The American School Counselor Association (ASCA), a division of the American Counseling Association, compiles a report each year on student-to-school counselor ratios, based on data from the U.S. Department of Education’s National Center for Education Statistics. ASCA’s latest report, released this week, included data on public K-12 schools in the 2014-2015 school year, which is the most recent information available.

“The work that school counselors do to support students’ academic, career, emotional and social development is absolutely critical,” says ACA President Gerard Lawson, an associate professor of counselor education at Virginia Tech. “In today’s schools, counselors are also relied on for their expertise in working with broader mental health needs. It is encouraging to see some improvements in the ratio of students to counselors, and we know that counselors can serve their students, schools and communities more effectively, when the ratio of students to counselors is lower and sustainable.”

The report highlights a disparity that exists across America. The highest ratio, with 924 students for every one school counselor, was Arizona, and the lowest, with a 202-to-1 ratio, was Vermont.

ASCA’s recommended student-to-school counselor ratio is 250-to-1.

“These counselor-to-student ratios are headed in the right direction, but they have a long, long way to go. More school counselors need to be hired, especially in states with the most egregious ratios,” says Nancy Carlson, a licensed clinical professional counselor and ACA’s on-staff counseling specialist.

 

Other highlights of the report:

 

  • States with the highest student-to-school counselor ratios were Arizona (924-to-1), California (760-to-1), Michigan (729-to-1), Minnesota (723-to-1), Utah (684-to-1), Illinois (664-to-1) and New York (635-to-1).

 

  • States with the lowest student-to-school counselor ratios were Vermont (202-to-1), Wyoming (219-to-1), Hawaii (293-to-1), North Dakota (307-to-1), Maine (315-to-1), Montana (319-to-1) and Tennessee (339-to-1).

 

  • California showed the most improvement over the previous year; the state’s ratio decreased 9 percent, from 822-to-1 (2013-2014) to 760-to-1 (2014-2015).

 

  • Alabama’s ratio also shifted 9 percent, but in the other direction. The state lost nearly 150 school counselors between 2013-2014 and 2014-2015, increasing its ratio from 417-to-1 to 453-to-1.

 

 

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ASCA’s full report, with a state-by-state breakdown, is available online: schoolcounselor.org/asca/media/asca/home/Ratios14-15.pdf

 

Read ASCA’s press release about this year’s numbers:  schoolcounselor.org/asca/media/asca/Press%20releases/ASCA-Student-to-SC-Ratios-Press-Release-10_2017-Final.pdf

 

The American Counseling Association’s School Counselor Connection page: counseling.org/knowledge-center/school-counselor-connection

 

 

 

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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 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.

 

 

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’13 Reasons Why’: Strengths, challenges and recommendations

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

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

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

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

 

Strengths

1) Raising awareness that suicide is a real problem.

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

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

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

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

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

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

3) Suicide is complex and individual.

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

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

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

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

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

4) The central message is a positive one.

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

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

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

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

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

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

 

Challenges

1) Graphic nature and contagion

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

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

2) Survivor’s guilt and revenge fantasies

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

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

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

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

 

Recommendations

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

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

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

2) We need more than prevention programming in schools.

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

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

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

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

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

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

4) Use an intervention model backed by research.

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

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

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

 

Summary

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

 

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

 

 

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

 

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

 

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

 

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

Bringing the family counseling perspective into schools

By S. Kent Butler, Tony D. Crespi and Mackenzie McNamara May 8, 2017

Children in schools today come from increasingly diverse and complex families. As illustration, more than 1 million families are impacted annually by divorce. In fact, approximately 13.7 million single parents are raising 21.8 million children, and 1 in 3 Americans are stepparents, stepchildren, stepsiblings or part of a stepfamily. Furthermore, according to a 2009 article published in the journal Family Relations, it is estimated that only 31 percent of fathers who no longer live with their children maintain weekly contact with those children. It is easy to conclude that the issue of divorce alone has a profound impact on many millions of children in the U.S.

Now imagine that a young student and her mother walk into the professional school counselor’s office on a Monday morning. Mom explains that she and her husband are pursuing a divorce — he recently told her that he’s been having an affair and has decided to move in with his girlfriend. The daughter acknowledges feelings of depression and admits to having angry outbursts at home. Mom says she is concerned because her daughter’s grades have been dropping.

Considering the large number of children and adolescents coping with parental divorce, it’s not surprising that this fragmented family came to the school counselor’s office. In fact, it’s a good thing. Both daughter and mother need someone to talk to, and schools are a natural access point for services. However, many professional school counselors are not trained in family dynamics and are not familiar with key tenets that impact family counseling, so they may not know how to proceed.

A sample case

Susie is 15. A high school freshman, she knows only that her father left the house two months ago to move in with his girlfriend. Susie’s parents had been together for 16 years, getting married shortly after college.

Susie’s father hasn’t called since leaving. Susie is unaware that her father told her mother that although he loves Susie and her younger sister, who is in seventh grade, he hasn’t missed seeing them in the least. Mom decided not to share this comment with the children, but she does confide this secret to you, the professional school counselor.

Sitting in your office, Susie suddenly looks up and exclaims that she is scared she will have to move and change schools. She also says that she’s having a really tough time paying attention in class and explains that her grades are slipping. “I hate my dad for doing this!” she yells.

Suddenly, Susie starts shaking and breaks down in tears. After a few minutes, Susie tells you that she is spending a lot of time with her boyfriend, partly to stay out of her house. She acknowledges feeling depressed. After pausing for a moment, she looks at her mom and states, “I really hate Dad. His girlfriend is so young. She’s in her 20s. She’s not much older than me!”

Academically, Susie has been an A and B student, but her grades have fallen since her father left. Her mother acknowledges that things are tough at home and reveals that she didn’t learn about her husband’s affair until the day he moved out. “I really don’t know what’s going to happen,” she tells you. “I know we’re getting a divorce, but beyond that I just don’t know.”

Your school doesn’t have a social worker. However, you have a colleague who has been studying family counseling, so you knock on her door to ask for a consultation. After sitting down, you share a few thoughts.

You note that, fundamentally, Susie needs someone to talk to about these issues. Acknowledging that you are speculating, you openly wonder what type of impact the obviously poor communication in Susie’s family is having on her. After all, her father has not called in two months, her mother was completely unaware of the affair and her mother is keeping the father’s confession of not missing his kids a secret. These facets alone highlight poor family communication. In addition, Susie is scared that she might have to move and change schools. Clearly the issues are widespread.

Risk points

Here are some risk points to consider as you work with Susie:

  • Parenting after a divorce differs significantly from parenting prior to
    a divorce.
  • Single-parent families in the United States are increasing.
  • Children of divorce have more mental health problems in comparison with their peers.
  • Suicide is the third-leading cause of death among U.S. youth.
  • Brain regions responsible for decision-making are not fully developed in youth.
  • Changes in family structure can have an affect on school grades.
  • Anxiety, depression and behavior problems are elevated after divorce.
  • Children of divorce often feel a sense of instability.

An understanding of these risk points is essential for moving forward with children and families because the risk points can provide direction for the work that needs to be done. For example, knowing that mental health symptoms are elevated following divorce and impulsive decision-making is greater among youth, you should assess Susie’s level of safety. In this case, Susie also makes many “red flag” statements.

These are things that counselors know how to address but might not always consider without an awareness of the data. In addition, parents can become defensive, or they might blame themselves for their children’s difficulties. For this reason, it is imperative to educate parents on these risk points. It is also important to realize that family issues may require clinical supervision.

Supervision around work with families 

Susie is not alone. As your colleague notes, Susie is one of many children and adolescents who are coping with family stressors. With the prevalence of so many family issues, a growing number of states have enabled licensed marriage and family therapists (LMFTs) to work in the schools. Connecticut, New Mexico, Maine, Texas and Illinois have passed specific laws to allow LMFTs to work in schools, whereas Massachusetts allows LMFTs to work under a general mental health designation.

Schools clearly represent an important access point for mental health professionals. But with only six states utilizing LMFTs in schools, it is extremely important for professional school counselors and their supervisors to know how to manage these situations with families.

As you ponder your next meeting with Susie, you need information. Direct supervisors are often part of the structure of many agencies, but professional school counselors might need to seek support from a colleague with training in family counseling. Such supervision might come from a guidance director, a school psychologist, a consulting psychologist, a marriage and family counselor, or a local family agency.

Two popular family therapy models that might help Susie are presented below.

Symbolic-experiential family therapy 

This model, derived from the work of Carl Whitaker, addresses both individual and relational patterns. It is focused on both personal growth and family relations.

Fundamentally, the therapist helps dislodge rigid patterns and stimulates flexibility using a family’s natural pull toward growth. Focusing on the present, the therapist helps people recognize their real feelings, express those feelings and move forward, individually and as a family. Key points follow.

  • The “battle for structure” involves clients (a family) “sizing up” a therapist. There is no “identified patient”; rather, the family is the therapy unit. In this model, the therapist must win the battle and control therapy. For instance, if the therapist invites the entire family and one member does not show up to the session, the therapist may refuse to meet until everyone attends. In the case with Susie, you might note that you, Susie, her mother and Susie’s sister must all attend.
  • The family must win the “battle for initiative”; this involves their decision to take charge of their lives and decisions. Is Susie committed to resolving her feelings? Will she commit to six counseling sessions? Is she willing to confront her father about calling his children? Is she motivated to initiate change?

Therapy progresses through stages:

1) Engagement: This is the “meet and greet” phase. You have already started this stage with Susie and her mom.

2) Middle phase: Families are encouraged to change through confrontations, encouragement and interventions. Can Susie’s family meet to start this process?

3) Late phase: Increased flexibility is a focus for the family. Can Susie’s family talk through how the divorce will change their life?

4) Separation: As the therapist separates, the family takes responsibility.

Symbolic-experiential family therapy often advocates the use of co-therapy, making it a great model to use with a more “senior” therapist. In this fashion, supervision can be active and ongoing as you acquire firsthand skills in family counseling.

Structural family therapy

The structural approach, typically associated with Salvador Minuchin, views problems as being rooted in family interactions. Fundamentally, if we can help change the family’s organization (structure), its members typically find that they feel better and their symptoms are often relieved. Key points follow.

  • Enmeshment or disengagement: Family members may range from those who are overly connected to those who are disengaged. Enmeshment tends to prevent growing maturity, whereas disengagement may lead a child to feel abandoned. Most families are not one or the other but have subsystems that reflect their tendencies. For example, a disengaged father who is overly involved at work may neglect the family. In response, the mother may compensate by becoming overly involved. Is Dad really connected? What is the structure
  • Boundaries: Are parental boundaries rigid or flexible? Are grandparents a resource? Can a child visit Dad at work, or does the family maintain a rigid rule against it? Can Susie ask Dad questions? What are the boundaries? What is spoken? What is unspoken?
  • Alignments: Who joins together? Are children aligned against the parents? Did a parent resent and refuse to attend a child’s sporting activities? Did a parent require everyone to attend? What are the alignments?
  • Triangulation: The permutations of triangulation in families can be abundant. A child and parent may triangulate against another parent. A parent having an affair can create a triangle with the other spouse. Will Susie triangulate with Mom against Dad? What triangles exit?

The structural model also features several stages:

1) Joining and accommodating

2) Assessing family interactions

3) Monitoring dysfunction

4) Restructuring patterns

Summary and considerations

When a student walks into a professional school counselor’s office, we are presented with a rare opportunity. When a student and parent walk in together, we are handed an even rarer opportunity.

Family counseling offers unique and engaging ways of reframing problems. Rather than blaming an individual for a particular problem, family counselors look at the family system. Perhaps a child’s acting-out behaviors allow parents to avoid looking at their relational problems. Perhaps a child’s failing grades reflect more on family anxiety and stress than on individual issues. Fundamentally, family counseling takes a larger, more systemic perspective of presenting issues.

Professional school counselors possess wonderful skill sets. They understand rapport building. They understand relational dynamics. They understand problem assessment and the utility of interventions. The connection between families and school adjustment is undeniable. At the same time, school counselors will likely find continuing education and supervision indispensable in helping families.

In our experience, students and families can often benefit from a family counseling perspective. With so many students in the schools coping with changing family structures, it is vital that we expand our skill sets. Fortunately, there are multiple platforms through which we can provide help. Some of these options include:

  • Individual counseling from a family perspective
  • Co-therapy with single families
  • School-based divorce groups with multiple children
  • Single-parent support groups

This article is intended to stimulate thinking and provide a preliminary glimpse into two prominent family counseling theories. Our advice? Be available. Be sensitive. Consider finding a supervisor who is capable of expanding your knowledge and skills in this invaluable area. Truly, children, families and the community stand only to benefit.

 

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S. Kent Butler is an associate professor at the University of Central Florida. He is a licensed professional counselor, national certified counselor and national certified school counselor. He is particularly interested in mentoring, supervision and multicultural issues in counseling. Contact him at skbutler@ucf.edu.

Tony D. Crespi is a professor at the University of Hartford. He is a certified school counselor, licensed marriage and family therapist, and licensed psychologist. He is particularly interested in family counseling and legal issues that affect supervision.

Mackenzie McNamara is a doctoral student in the counseling psychology program at the University at Albany, State University of New York. She most recently worked for New London Public Schools in Connecticut.

Letters to the editor: ct@counseling.org

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

 

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