Tag Archives: Children & Adolescents

Children & Adolescents

Understanding and treating survivors of incest

By David M. Lawson March 6, 2018

Adults with histories of being abused as children present unique challenges for counselors. For instance, these clients often struggle with establishing and maintaining a therapeutic alliance. They may rapidly shift their notion of the counselor from very favorable to very unfavorable in line with concomitant shifts in their emotional states. Furthermore, they may anxiously expect the counselor to abandon them and thus increase pressure on the counselor to prove otherwise. Ironically, attempts at reassurance by the counselor may actually serve to validate these clients’ fears of abandonment.

The motivating factor for many of these clients is mistrust of people in general — and often for good reason. This article explores the psychological and interpersonal aspect of child sexual abuse by a parent and its treatment, with a particular focus on its relationship to betrayal trauma, dissociation and complex trauma.

Incest and its effects

Child abuse of any kind by a parent is a particularly negative experience that often affects survivors to varying degrees throughout their lives. However, child sexual abuse committed by a parent or other relative — that is, incest — is associated with particularly severe psychological symptoms and physical injuries for many survivors. For example, survivors of father-daughter incest are more likely to report feeling depressed, damaged and psychologically injured than are survivors of other types of child abuse. They are also more likely to report being estranged from one or both parents and having been shamed by others when they tried to share their experience. Additional symptoms include low self-esteem, self-loathing, somatization, low self-efficacy, pervasive interpersonal difficulties and feelings of contamination, worthlessness, shame and helplessness.

One particularly damaging result of incest is trauma bonding, in which survivors incorporate the aberrant views of their abusers about the incestuous relationship. As a result, victims frequently associate the abuse with a distorted form of caring and affection that later negatively influences their choice of romantic relationships. This can often lead to entering a series of abusive relationships.

According to Christine Courtois (Healing the Incest Wound: Adult Survivors in Therapy) and Richard Kluft (“Ramifications of incest” in Psychiatric Times), greater symptom severity for incest survivors is associated with:

  • Longer duration of abuse
  • Frequent abuse episodes
  • Penetration
  • High degree of force, coercion and intimidation
  • Transgenerational incest
  • A male perpetrator
  • Closeness of the relationship
  • Passive or willing participation
  • Having an erotic response
  • Self-blame and shame
  • Observed or reported incest that continues
  • Parental blame and negative judgment
  • Failed institutional responses: shaming, blaming, ineffectual effort
  • Early childhood onset

Incest that begins at a young age and continues for protracted periods — the average length of incest abuse is four years — often results in avoidance-based coping skills (for example, avoidance of relationships and various dissociative phenomena). These trauma-forged coping skills form the foundation for present and future interpersonal interactions and often become first-line responses to all or most levels of distress-producing circumstances.

More than any other type of child abuse, incest is associated with secrecy, betrayal, powerlessness, guilt, conflicted loyalty, fear of reprisal and self-blame/shame. It is of little surprise then that only 30 percent of incest cases are reported by survivors. The most reliable research suggests that 1 in 20 families with a female child have histories of father-daughter child sexual abuse, whereas 1 in 7 blended families with a female child have experienced stepfather-stepdaughter child sexual abuse (see the revised edition of The Secret Trauma: Incest in the Lives of Girls and Women by Diana E. H. Russell, published in 1999).

In 1986, David Finkelhor, known for his work on child sexual abuse, indicated that among males who reported being sexually abused as children, 3 percent reported mother-son incest. However, most incest-related research has focused on father-daughter or stepfather-stepdaughter incest, which is the focus of this article.

Subsequent studies of incest survivors indicated that being eroticized early in life disrupted these individuals’ adult sexuality. In comparison with nonincest controls, survivors experienced sexual intercourse earlier, had more sex partners, were more likely to have casual sex with those outside of their primary relationships and were more likely to engage in sex for money. Thus, survivors of incest are at an increased risk for revictimization, often without a conscious realization that they are being abused. This issue often creates confusion for survivors because the line between involuntary and voluntary participation in sexual behavior is blurred.

An article by Sandra Stroebel and colleagues, published in 2013 in Sexual Abuse: A Journal of Research and Treatment, indicates that risk factors for father-daughter incest include the following:

  • Exposure to parent verbal or physical violence
  • Families that accept father-daughter nudity
  • Families in which the mother never kisses or hugs her daughter (overt maternal affection was identified as a protective factor against father-daughter incest)
  • Families with an adult male other than the biological father in the home (i.e., a stepfather or substitute father figure)

Finally, some qualitative research notes that in limited cases, mothers with histories of being sexually abused as a child wittingly or unwittingly contribute to the causal chain of events leading to father-daughter incest. Furthermore, in cases in which a mother chooses the abuser over her daughter, the abandonment by the mother may have a greater negative impact on her daughter than did the abuse itself. This rejection not only reinforces the victim’s sense of worthlessness and shame but also suggests to her that she somehow “deserved” the abuse. As a result, revictimization often becomes the rule rather than the exception, a self-fulfilling prophecy that validates the victim’s sense of core unworthiness.

Beyond the physical and psychological harm caused by father-daughter incest, Courtois notes that the resulting family dynamics are characterized by:

  • Parent conflict
  • Contradicting messages
  • Triangulation (for example, parents aligned against the child or perpetrator parent-child alignment against the other parent)
  • Improper parent-child alliances within an atmosphere of denial and secrecy

Furthermore, victims are less likely to receive support and protection due to family denial and loyalty than if the abuser were outside the family or a stranger. Together, these circumstances often create for survivors a distorted sense of self and distorted relationships with self and others. If the incest begins at an early age, survivors often develop an inherent sense of mistrust and danger that pervades and mediates their perceptions of relationships and the world as a whole.

Betrayal trauma theory

Betrayal trauma theory is often associated with incest. Psychologist Jennifer Freyd introduced the concept to explain the effects of trauma perpetrated by someone on whom a child depends. Freyd holds that betrayal trauma is more psychologically harmful than trauma committed or caused by a noncaregiver. “Betrayal trauma theory posits that under certain conditions, betrayals necessitate a ‘betrayal blindness’ in which the betrayed person does not have conscious awareness or memory of the betrayal,” Freyd wrote in her book Betrayal Trauma: The Logic of Forgetting Childhood Abuse.

Betrayal trauma theory is based on attachment theory and is consistent with the view that it is adaptive to block from awareness most or all information about abuse (particularly incest) committed by a caregiver. Otherwise, total awareness of the abuse would acknowledge betrayal information that could endanger the attachment relationship. This “betrayal blindness” can be viewed as an evolutionary and nonpathological adaptive reaction to a threat to the attachment relationship with the abuser that thus explains the underlying dissociative amnesia in survivors of incest. Under these circumstances, survivors often are unaware that they are being abused, or they will justify or even blame themselves for the abuse. In severe cases, victims often have little or no memory of the abuse or complete betrayal blindness. Under such conditions, dissociation is functional for the victim, at least for a time.

Consider the case of “Ann,” who had been repeatedly and severely physically and sexually abused by her father from ages 4 to 16. As an adult, Ann had little to no memory of the abuse. As a result of the abuse, she had developed nine alternate identities, two of which contained vivid memories of the sexual and physical abuse. Through counseling, she was able to gain awareness of and access to all nine alternate identities and their functions.

Although Ann expressed revulsion and anger toward her father, she also expressed her love for him. At times, she would lapse into moments of regret for disclosing the abuse, saying that “it wasn’t so bad” and that the worst thing that had happened was that she had lost her “daddy.” During these moments, Ann minimized the severity of the abuse, wishing that she had kept the incest secret so that she could still have a relationship with her father. This was an intermittent longing for Ann that occurred throughout counseling and beyond.

Thus, understanding attachment concepts is critical for understanding betrayal traumas such as incest. Otherwise, counselors might be inclined to blame survivors or might feel confused and even repulsed by survivors’ behaviors and intentions. For many survivors, the caregiver-abuser represents the best and the worst of her life at various times. She needs empathy and support, not blame.

Dissociation

As defined in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, dissociation is “a disruption of and/or discontinuity in the normal integration of consciousness, memory, identity, perception, body representation, motor control and behavior.” Depending on the severity of the abuse, dissociative experiences can interfere with psychological functioning across the board. Survivors of incest often experience some of the most severe types of dissociation, such as dissociative identity disorder and dissociative amnesia (the inability to recall autobiographical information). Dissociative experiences often are triggered by perceived threat at a conscious or unconscious level.

As previously noted, betrayal trauma theory holds that for incest survivors, dissociative amnesia serves to maintain connection with an attachment figure by excluding knowledge of the abuse (betrayal blindness). This in turn reduces or eliminates anxiety about the abuse, at least in the short run. Conversely, many survivors of childhood incest report continuous memories of the abuse, as well as the anxiety and felt terror related to the abuse. Often, these individuals will find a way to leave their homes and abusers. This is less frequently the case for survivors who experience dissociative amnesia or dissociative identity disorder.

Depersonalization and derealization distort the individual’s sense of self and her sensory input of the environment through the five senses. For example, clients who have experienced incest often report that their external world, including people, shapes, sizes, colors and intensities of these perceptions, can change quickly and dramatically at times. Furthermore, they may report that they do not recognize themselves in a mirror, causing them to mistrust their own perceptions.

As one 31-year-old incest survivor stated, “For so many years, everything within me and around me felt and looked unreal, dull, dreary, fragmented, distant.” This is an example of depersonalization/derealization. She continued, “This, along with the memory gaps, forgetfulness and inability to recall simple everyday how-tos, like how to drive a car or remember the step-by-step process of getting ready for the day, made me feel crazy. But as I improved in counseling, my perceptions of my inside and outside worlds became clearer, more stable, and brighter and more distinct than before counseling. It all came to make more sense and feel right. It took me years to see the world as I think other people see it. From time to time I still experience that disconnection and confusion, but so much less frequently now than before.”

Initially, some real or perceived threat triggers these distorted perceptions of self and outer reality, but eventually they become a preset manner of perceiving the world. Reports such as this one are not uncommon for survivors of incest and often are exacerbated as these individuals work through the process of remembering and integrating trauma experiences into a coherent life narrative. For many survivors, a sense of coherence and stability is largely a new experience; for some, it can be threatening and trigger additional dissociative experiences. The saying “better a familiar devil than an unfamiliar angel” seems to apply here.

The severity of dissociation for survivors of incest is related to age onset of trauma exposure and a dose-response association, with earlier onset, more types of abuse and greater frequency of abuse associated with more severe impairment across the life span. Incest is associated with the most severe forms of dissociative symptoms such as dissociative identity disorder. Approximately 95 to 97 percent of individuals with dissociative identity disorder report experiencing severe childhood sexual and physical abuse.

Fragmentation in one’s sense of self, accompanied by amnesia of abuse memories, is particularly functional when children cannot escape the abuse circumstances. These children are not “present” during the abuse, so they often are not aware of the physical and emotional pain associated with the abuse. Yet this fragmented sense of self contributes to a sense of emptiness and absence, memory problems and dissociative self-states. Many survivors of incest are able to “forget” about the abuse until sometime later in adulthood when memories are triggered by certain events or when the body and mind are no longer able to conceal the memories. The latter results from the cumulative effect of lifelong struggles related to the incest (for example, interpersonal problems and emotional dysregulation). It takes a great deal of psychological and physical resources to “forget” trauma memories.

Dissociation, especially if it involves ongoing changes in perceptions of self and others, different presentations of self and memory problems, may result in difficulty forming and maintaining a therapeutic alliance. Dissociation disrupts the connection between the client and the counselor. It also disrupts clients’ connections with their inner experience. If these clients do not perceive themselves and their surroundings as stable, they will mistrust not only their counselors but also their own perceptions, which create ongoing confusion.

Thus, counselors must remain alert to subtle or dramatic fluctuations in survivors’ presentation styles, such as changes in eye contact or shifts in facial features from more engaged and animated to flat facial features. Changes in voice tone quality and cadence (from verbally engaged to silent) or in body posture (open versus closed) are other signs of possible dissociative phenomena. Of course, all or none of these changes may be indicators of dissociative phenomena.

Complex trauma

Incest, betrayal trauma and dissociative disorders are often features of a larger diagnostic categorization — complex trauma. Incest survivors rarely experience a single incident of sexual abuse or only sexual abuse. It is more likely that they experience chronic, multiple types of abuse, including sexual, physical, emotional and psychological, within the caregiving system by adults who are expected to provide security and nurturance.

Currently, an official diagnostic category for complex trauma does not exist, but one is expected to be added to the revised International Classification of Diseases (ICD-11) that is currently in development. Marylene Cloitre, a member of the World Health Organization ICD-11 stress and trauma disorders working group, notes that the new complex trauma diagnosis focuses on problems in self-organization resulting from repeated/chronic exposure to traumatic stressors from which one cannot escape, including childhood abuse and domestic violence. Among the criteria she highlighted for complex trauma are:

  • Disturbances in emotions: Affect dysregulation, heightened emotional reactivity, violent outbursts, impulsive and reckless behavior, and dissociation.
  • Disturbances in self: Defeated/diminished self, marked by feeling diminished, defeated and worthless and having feelings of shame, guilt or despair (extends despair).
  • Disturbances in relationships: Interpersonal problems marked by difficulties in feeling close to others and having little interest in relationships or social engagement more generally.
    There may be occasional relationships, but the person has great difficulty maintaining them.

Early onset of incest along with chronic exposure to complex trauma contexts interrupts typical neurological development, often leading to a shift from learning brain (prefrontal cortex) to survival brain (brainstem) functioning. As explained by Christine Courtois and Julian Ford, survivors experience greater activation of the primitive brain, resulting in a survival mode rather than activation of brain structures that function to make complex adjustments to the current environment. As a result, survivors often exhibit an inclination toward threat avoidance rather than being curious and open to experiences. Complex trauma undermines survivors’ ability to fully integrate sensory, emotional and cognitive data into an organized, coherent whole. This lack of a consistent and coherent sense of self and one’s surroundings can create a near ever-present sense of confusion and disconnection from self and others.

Regular or intermittent complex trauma exposure creates an almost continual state of anxiety and hypervigilance and the intrinsic expectation of danger. Incest survivors are at an increased risk for multiple impairments, revictimization and loss of support.

Treatment issues

Although a comprehensive description of treatment is well beyond the scope of this article, I will close with a general overview of treatment concepts. Treatment for incest parallels the treatment approaches for complex trauma, which emphasizes symptom reduction, development of self-capacities (emotional regulation, interpersonal relatedness and identity), trauma processing and the addressing of dissociative experiences.

Compromised self-capacities intensify symptom severity and chronicity. Among these self-capacities, emotional dysregulation is a major symptom cluster that affects other self-capacity components. For example, if a survivor consistently struggles with low frustration tolerance for people and copes by avoiding people, responding defensively, responding in a placating manner or dissociating, she likely will not have the opportunity to develop fulfilling relationships. The following core concepts, published in the May 2005 Psychiatric Annals, were suggested by Alexandra Cook and colleagues for consideration when implementing a treatment regimen for complex trauma, including with incest survivors and with adaptations for clients with dissociative identity disorder.

1) Safety: Develop internal and environmental safety procedures.

2) Self-regulation: Enhance the capacity to moderate and rebalance arousal across the areas of affective state, behavior, physiology, cognition, interpersonal relatedness and self-attribution.

3) Self-reflective information processing: Develop the ability to focus attentional processes and executive functioning on the construction of coherent self-narratives, reflecting on past and present experience, anticipation and planning, and decision-making.

4) Traumatic experiences integration: Engage in resolution and integration of traumatic memories and associated symptoms through meaning making, traumatic memory processing, remembrance and mourning of traumatic loss, development of coping skills, and fostering present-oriented thinking and behavior.

5) Relational engagement: Repair, restore or create effective working models of attachment and application of these models to current interpersonal relationships, including the therapeutic alliance. Emphasis should be placed on development of interpersonal skills such as assertiveness, cooperation, perspective taking, boundary and limit setting, reciprocity, social empathy and the capacity for physical and emotional intimacy.

6) Positive affect enhancement: Work on the enhancement of self-worth, self-esteem and positive self-appraisal through the cultivation of personal creativity, imagination, future orientation, achievement, competence, mastery seeking, community building and the capacity to experience pleasure.

Typically, these components are delivered within a three-phase model of counseling that is relationship-based, cognitive behavioral in nature and trauma focused:

  • Safety, self-regulation skill development and alliance formation
  • Trauma processing
  • Consolidation

The relational engagement component is particularly critical because for many survivors, to be attached often has meant to be abused. Furthermore, accompanying feelings of shame, self-loathing and fear of abandonment create a “failure identity” that results in low expectations for change. Additionally, it is important for counselors to attend to client transference issues and counselor countertransference issues. Courtois suggests that ignoring or assuming that such processes are irrelevant to the treatment of survivors can undermine the treatment process and outcome.

In addition, strength-based interventions are critical in each phase to help survivors develop a sense of self-efficacy and self-appreciation for the resources they already possess. A strength-based focus also contributes to client resilience.

For some clients, dissociated self-states or parts will emerge. Counselors should assume that whatever is said to one part will also be heard by the other parts. Therefore, addressing issues in a manner that encourages conversation between parts, including the core self-structure, is critical. It is also important to help parts problem-solve together and support each other. This is not always an easy proposition. A long-term goal would be some form of integration/fusion or accord among alternate identities. Some survivors eventually experience full unification of parts, whereas others achieve a workable form of integration without ever fully unifying all of their alternate identities (for more, see Treating Trauma-Related Dissociation: A Practical, Integrative Approach by Kathy Steele, Suzette Boon and Onno van der Hart).

Finally, it must be mentioned that repeated exposure to horrific stories of incest can overwhelm counselors’ capacity to maintain a balanced relationship with clear boundaries. A client’s transference can push the boundaries of an ethical and therapeutic client-counselor relationship. Furthermore, the frequent push-pull dynamics between counselor and client can be exhausting, both physically and mentally for counselors. Therefore, it is important for counselors to frequently seek supervision and consultation and to engage in self-care physically, psychologically and spiritually.

 

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

David M. Lawson is a professor of counselor education and director of the Center for Research and Clinical Training in Trauma at Sam Houston State University. His research focuses on childhood sexual and physical abuse, complex trauma and dissociation related to trauma. He also maintains an independent practice focusing on survivors of posttraumatic stress disorder and complex trauma. Contact him at dml3466@aol.com.

Letters to the editorct@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.

 

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.

Giving children a voice in addiction recovery

By Bethany Bray December 4, 2017

When treating clients struggling with substance abuse, Lindsey Chadwick would like her fellow counselors to keep in mind the toll that addiction takes on children. Addiction affects the whole household. Children feel the effects differently — but as acutely — as adults, says Chadwick, a licensed professional counselor and manager of the children’s program at the Betty Ford Center, part of the Hazelden Betty Ford Foundation, just outside of Denver, Colorado.

“Simply being aware [of the fact] that kids are affected by addiction is a huge piece of the advocacy work that we do,” says Chadwick, a member of the American Counseling Association. “Even if a counselor is working [in addictions] with adults, be thinking of the kids. They are a big part of their grown-ups’ recovery. They matter. Take into account what the kids have to say.”

Chadwick and her colleagues run a program for children, ages 7 to 12, who come from addicted homes. The child’s “grown-up,” a parent, relative or caregiver, receives treatment simultaneously through the Betty Ford Center’s programming for adults. The children come for an intensive, four-day workshop that focuses on coping skills and education on what addiction is, and – most importantly – that it’s not their fault, says Chadwick.

“Most of all, we try and help them have fun and be a kid. They are often caught up in very grown-up situations at home,” says Chadwick.

Children from homes where  addiction is present often  take on roles they’re too young to play, such as caring for younger siblings or being a peacemaker or mediator in the home, she

Lindsey Chadwick at work in the children’s program at the Betty Ford Center just outside of Denver, Colorado.

explains. At Betty Ford, Chadwick and her colleagues do a lot of role-play, sharing activities and psychoeducational games with the children, as well as non-therapeutic games, snacks and swimming at a nearby pool.

“For the most part, on the surface, our kids look like any other kids,” says Chadwick. “But we see a lot who are struggling with anger toward their grown-up or family members. We see a lot of very anxious and nervous kids who have taken on a lot of adult roles because they needed to.  Some of our kids have also experienced abuse and neglect. Addiction is an equal-opportunity disease, so we see it in all kinds of families.”

Children who come through the program often struggle with perfectionism, an extreme focus on maintaining control and “not making waves,” says Chadwick. Also, children who come from addicted homes often experience loneliness and guilt or feel like their family is not as good as others.

Many children feel like the addiction is somehow their fault – a message they focus on reversing, says Chadwick.

“We teach them that many people go through what they’re going through,” she says. “We want them to really learn their strengths. Despite the addiction, it doesn’t mean that they can’t love their family, or that other things [in their life] aren’t going well.”

In households with addiction, feelings and problems are not usually talked about or addressed. This unwritten “rule” of not talking about struggles or emotions is passed from older to younger generations, Chadwick says. At Betty Ford, they work to undo those patterns, teaching children to express what they’re feeling – with an aim to keep them from falling into addiction when older.

“A lot of our kids don’t have the language [to express the struggles of addiction]. We try to give them the language to talk about what’s going on, to identify what’s wrong and tell someone,” says Chadwick. “… We give them the space to know that they matter, and it’s OK to let things out.”

In addition to talking to express themselves, they teach the youngsters nonverbal ways to let out their emotions, such as drawing, physical activity and other self-care activities. They also identify who is safe to talk to (i.e., a counselor, trusted adult or peer) and when. “Addiction sometimes confuses that for them,” explains Chadwick.

“We have kids who come in, and they’re angry, sad or mad, and they don’t want to be here,” she says. “On the last day [of the program], they’re happy and smiling – they’re a kid again. It’s such a wonderful transformation to be a part of.”

Psychoeducation activities at the Betty Ford children’s program also involve a cartoon character named Beamer. He stars in a series of books that the Betty Ford Center uses in their children’s program.

Both of Beamer’s parents struggle with addiction, and one is in recovery, and the other is not, explains Chadwick. Beamer navigates the ups and downs of living in a household coping with addiction in each of the books.

“Kids really love Beamer because they’ve never really seen a character that’s going through the same things as they are,” Chadwick says. “It’s very validating to learn that they’re not alone. They relate to him. A lot of the situations he’s been in, they’ve been in – his struggles at school and interactions with family. It gives them a vehicle to talk about it as well, and helps them feel more comfortable.”

Betty Ford counselors sometimes encourage the children to write Beamer letters as a therapeutic tool, adds Chadwick.

All families who go through recovery programs at the Betty Ford Center are referred for therapy in their local area. They are also invited back for weekly follow-up programming and support groups.

Chadwick has worked for nine years at the children’s program at the Betty Ford Center. In addition to Chadwick’s program in Colorado, Betty Ford also offers children’s programming at centers in Dallas and Rancho Mirage, California.

“I grew up in a family where addiction was a problem for multiple generations. I saw things that I shouldn’t have as a kid. I’m happy to give back to these families,” says Chadwick. “It’s so amazing, as a therapist, you get to work with the kids on their level and have so much fun throughout the day, but also help focus on recovery … It’s really amazing to watch these families heal. The adults in the [Betty Ford Center] program really want what’s best for their families, and it’s wonderful to be part of that process.”

 

 

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Find out more about the Hazelden Betty Ford Foundation’s children’s program at hazeldenbettyford.org/treatment/family-children/childrens-program

More information on the “Beamer” character and materials can be found at mybeamersworld.com

 

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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 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.

 

 

Tools for navigating the world at large

By Laurie Meyers November 22, 2017

By the time children with autism spectrum disorder (ASD) are approaching elementary school age, they are already exhibiting symptoms that typically lead to lifelong social difficulties. Among these symptoms: impaired communication and interaction, an inability to self-regulate and modulate emotions, very narrow and specific interests, and sensory processing difficulties that make it difficult for them to connect with the world at large.

Many counselor practitioners may question whether they are even qualified to work with clients who have ASD. According to the individuals interviewed for this article, however, professional counselors possess a range of skills that can be particularly helpful to this client population.

Stephanie Smigiel, a licensed professional counselor (LPC) who does mobile counseling with ASD clients in the Pittsburgh area as part of the state of Pennsylvania’s behavioral health services, says clients with autism aren’t that different from other populations with which counselors work. She acknowledges that these clients often require a little extra accommodation and counselor ingenuity, but this call to be creative is one of the reasons that she particularly enjoys working with the population.

It is essential, however, that counselors understand clients with ASD and their needs, cautions Smigiel, a member of the American Counseling Association. “Ask yourself, ‘Do I have a bias? Is this a population I can see myself working with?” She notes that people with ASD can have problems controlling their aggression and says it is not uncommon for these clients, sometimes including adults, to pull her hair or scratch her arms.

Neurology tells us that the brains of those with ASD work differently. Those on the spectrum are often labeled as atypical (as opposed to neurotypical). However, those with ASD and many of the people who work with them have begun advocating for a different view: neurodiversity — or the idea that there is no single, correct neurology.

“The neurodiversity movement in the field seeks to apply a culturally competent view of people diagnosed with ASD or other neurological or neurodevelopmental diagnoses,” explains Ali Cunningham, a licensed mental health counselor (LMHC) who specializes in ASD. “As with most cultural groups who are trying to acculturate to the majority group, it is about achieving a balance of honoring individuality and uniqueness while striving to be successful in the majority.”

Cunningham says that many clients with autism struggle with wanting to maintain what makes them unique while still being able to connect with others and navigate the worlds of friendship, romance and work. Culturally sensitive treatment of clients with ASD involves helping them identify how their individuality or uniqueness is a resource while also exploring what new skills or techniques they are willing to integrate into their lives to strike that balance, she says.

“I always try to communicate the message that treatment is not intended to change who you are,” Cunningham says. “Treatment can help highlight the strengths you already have and add to them with skills or techniques that will enhance how you navigate the world and help you meet your goals.”

Boy (and girl) meets world

Because ASD presents early in life, experts in the field emphasize the importance of early intervention. One of the primary ways that professional counselors can help clients with ASD manage the challenges that come with the disorder is by targeting and teaching social skills.

Tami Sullivan, an LMHC and registered play therapist, maintains a private practice in Brockport, New York, that includes ASD as one of its specialties. She uses play therapy to connect with child clients who have autism.

“Children often make sense of their world and the people in it through play,” says Sullivan, a member of ACA. “Play can be used as an intervention [because] it is the native language of childhood. Counselors can understand children, the child’s world and his or her perspectives in the context of play therapy.”

Sullivan notes that children with autism play differently than do their peers without autism. “Children with autism have a low level of engagement in play. Their play is more concrete, private, ritualized … and restrictive,” she says.

She explains that young children with ASD possess limited imaginary or “pretend” play skills. Their tendency to engage exclusively in solo play and difficulty participating in imaginary worlds isolates these children and often precludes them from developing meaningful relationships or friendships with other children.

Sullivan uses a nondirective play therapy approach to engage children who have ASD. This means that rather than using a prescribed set of games or toys, she lets the child take the lead, exploring at his or her own pace.

“In this nondirective approach, the relationship is the key therapeutic medium [that] communicates acceptance of the child,” says Sullivan, an assistant professor in the Counseling and Psychological Services Department at the State University of New York at Oswego. “I aim to make the critical emotional connections that support a reciprocal relationship between us. I … encourage [the child’s] initiative and play with the goal of deepening engagement, lengthening mutual attention and regulating emotion and behavior.”

Once these children feel fully accepted, they begin to communicate and engage in reciprocal social interactions, Sullivan says.

When Sullivan wants to target a specific therapeutic goal, she uses more directive play, choosing activities that help build particular strengths in children with autism. For example, by creating something with the child, Sullivan strengthens the child’s ability to take turns, joint attention (the ability to focus on more than one thing at a time) and social perspective.

Sensory exploration can further increase the connection between Sullivan and the child. Many children with ASD use sensory toys to self-regulate, so in addition to baskets of sensory toys, Sullivan has sand trays, big bean bags and pillows, donut balls, a tunnel and a small ball pit in her office. “I am often invited by them to join in as they self-regulate,” Sullivan says. “This can be a time to connect deeper with the child and build our relationship.”

Sullivan collaborates with her clients’ parents or caregivers using two therapeutic approaches: skills-based/solution-focused therapy and filial therapy.

The first approach involves identifying goals and solutions for the child’s behavior and challenges that are causing stress on the family system. Sullivan then works with the parents to identify ways in which they can support and encourage the child as he or she develops new skills and abilities.

For example, children with autism often express anxiety through their behavior. Sullivan teaches parents how to identify this and how to help children recognize what they are feeling. The parents can then prompt their children to use coping skills they have learned with Sullivan, such as relaxing their bodies, distracting themselves or trying to change the way they feel about a situation.

With filial therapy, Sullivan says the work centers around strengthening the parent-child relationship in the counseling process. This is done in part by teaching parents play therapy relationship-building techniques such as reflecting the child’s feelings, empathic listening, imaginary play skills and limit setting.

Finding friends

During the elementary, middle school and high school years, social skills become even more critical, Sullivan says, particularly as they relate to the making and keeping of friends. “These children [her clients with ASD] desperately want to have friends, but they don’t know how,” she says.

Sullivan uses group therapy to help children with autism cultivate stronger social and relationship skills. She holds one group for children of elementary school age and another for clients of middle and young high school age.

When designing the groups, Sullivan decided the training for the elementary school-age children would be more effective if it featured an element of play. She chose to incorporate Lego-based therapy, a method pioneered by neuropsychologist Daniel LeGoff after he noticed that when children with ASD worked together to build things, they were more naturally inclined to socialize with each other. Sullivan pairs the Lego therapy with a structured lesson. She says the underlying play therapy lessens the children’s anxiety about the group while the building exercises aid in teaching social and friendship skills.

The group meets for 90 minutes once a week for 10 weeks. It is run by a professional counselor (either Sullivan or her colleague) and a relational coach who demonstrates social skills by engaging in role-play with the counselor.

Each session starts with a sensory warmup in which group members can play with sensory toys. After the warmup, the leaders and participants decide, as a group, what kind of Lego structure they want to build that day. The building process is collaborative and uses defined roles such as builder, supplier and engineer. From session to session, the children take turns playing each role. Once roles are assigned, the group must work together to decide how to go about building the structure.

As the group is building, the leaders introduce that session’s topic, such as learning how to have a conversation. The counselor talks about what the skill involves — in this case, trading information — and demonstrates it through role-play with the relational coach. This often consists of “good” role-play and “bad” role-play. For example, you don’t start a conversation by going up and introducing yourself, but you do hang back and wait until a topic comes up that interests you and then join the conversation.

Sessions end in free play, during which the children, over time, begin to interact with each other on their own, Sullivan says. The children’s parents or other family members receive a sheet after each session that outlines the skills the group worked on that week. As homework, parents are encouraged to help their children practice the skills they learned in group.

If possible, Sullivan also provides packets for the children’s teachers. She says that in some cases, teachers call her to collaborate, whereas in others, the parents work with the teachers. Many of the children in Sullivan’s groups are in mainstream classrooms. So, she recommends that their teachers identify peers to serve as social mentors and then provide time for the students with ASD to practice their skills at school.

The group also explores appropriate humor, a topic for which bad role-play is particularly suited, Sullivan says. The relational coach will display inappropriate humor — for instance, using potty language or imitating one kid making fun of another kid — and the counselor will react. Afterward, the coach and counselor ask the group members what they saw: “Did you notice that Tami didn’t laugh and that she actually looked kind of sad?” Then the coach demonstrates appropriate humor by telling a joke, and in response, Sullivan or her colleague will laugh. Sullivan also gives the children (and their parents) a list of appropriate topics to joke about and recommends joke books.

The group also discusses how to be a good sport. “We talk about a lot of things that you don’t do when you want to play a game with someone,” Sullivan says. For instance, “You don’t want to be a policeman or a referee — you don’t want to remind everyone what the rules are all the time.” The lesson teaches children to focus on what their role is in the game and how to participate in a sharing way. The topic also offers an excellent opportunity to talk with group members about additional skills such as dealing with frustration by walking away, taking a break or engaging in deep breathing, she says.

In later weeks, the group experience involves more discussion, such as talking about how to choose an appropriate friend. The children compile lists of qualities that are appealing to them in a friend and what makes a person a bad friend, Sullivan says. She also works with parents to help them brainstorm places, such as school clubs, where children can make positive connections.

Sullivan says the group leaders routinely look for opportunities to point out when children are demonstrating some of the skills they have learned in the group. Recently, during freestyle play, one boy, inspired by the monster structures they had been building, talked about wanting to have a Halloween party. His fellow group members then asked one another about their Halloween costumes and activities.

Teenage training

Sullivan’s group for clients of middle school and younger high school age runs for 14 weeks. It also focuses on conversational skills but covers additional topics such as how to handle rejection, how to handle rumors and gossip and how to be a good host. This group doesn’t incorporate Lego therapy. Instead of starting sessions with sensory play like the younger group, participants in the older group talk about their experiences trying to implement the skills they are learning. They also receive more homework to reinforce those skills.

Sullivan says the group spends a significant amount of time talking about bullying, rumors and gossip. “We teach a lot about how to reinvent yourself,” she says.

For instance, the group leaders emphasize that it is counterproductive to handle rumors or gossip by addressing them directly or denying them because those actions merely create more rumors and gossip, Sullivan says. Instead, they teach participants to redirect by using a sense of humor, walk away if someone is getting in their face and establish support figures in school and at home. They also talk about what to do about a damaged reputation, how to not take rumors and gossip personally, how to find other groups to hang out with and how to identify and connect with supporters within the school.

Sullivan says participants practice skills together during the group sessions, but group leaders also encourage them to set up short get-togethers with friends outside of group. In doing so, the leaders emphasize the need for the group members to practice sharing and exchanging ideas with others during these get-togethers. What group leaders don’t want is for group participants simply to get together for parallel play, such as two people playing video games separately, side by side, Sullivan says.

Group leaders review the process of getting together in great depth, even covering actions as simple as answering the door. “You don’t just open it,” Sullivan tells group members. “Invite the friend in and ask what they want to do.”

Next, the host should present the friend with two possible activities to choose from and let the friend decide which sounds more fun. Once they complete that activity, the host should talk with the friend about what else they could do, Sullivan coaches.

The sessions for Sullivan’s group incorporate ideas from the Program for the Education and Enrichment of Relational Skills (PEERS) for Adolescents model, an evidence-based social skills intervention developed by UCLA’s Semel Institute for Neuroscience and Human Behavior. PEERS focuses on the following topics:

  • How to use appropriate conversational skills
  • How to choose appropriate friends
  • How to appropriately use electronic forms of communication 
  • How to appropriately use humor and assess humor feedback
  • How to start, enter and exit conversations between peers
  • How to organize successful get-togethers with friends
  • How to be a good sport when playing games or sports with friends
  • How to handle arguments and disagreements with friends and in relationships
  • How to handle rejection, teasing, bullying, rumors/gossip and cyberbullying
  • How to change a bad reputation

Conversation starters

Cunningham, who practices at the Children’s Center for Psychiatry, Psychology and Related Services in Delray Beach, Florida, also uses the PEERS for Adolescents program with middle school- and high school-age youth. The groups last 16 weeks, and participants must be accompanied by a parent or someone else who functions as a social coach, she says. The “coach” requirement is in place so that the youth will have support not only for practicing their skills but also for finding opportunities for social engagement, Cunningham says. The clients with ASD meet in one group, while the parents/social coaches meet in a separate group to learn about the skills the youth are acquiring.

Cunningham, an assistant professor of counseling at Lynn University in Boca Raton, says that sessions start with role-play. Facilitators model some common errors related to that week’s skill lessons so that group members can learn what not to do. The facilitators then use role-play to demonstrate scenarios for using the skills effectively. The group participants then rehearse the skills and are given homework requiring them to go out and practice their skills in the outside world.

The group spends a substantial amount of time on conversational skills, beginning with how to start one, Cunningham says. Most people might say that the way to start a conversation is by introducing yourself, but few people actually do that, she notes, because it makes it seem like you’re selling something. Instead, group members learn how to find something that they have in common with the person and then make a comment or ask a question to continue the conversation, she explains.

People with ASD often have very particular, idiosyncratic interests, Cunningham says, so group participants learn about things that most people like to talk about, such as books, TV shows, movies, music or video games. She also tries to help clients understand steps they can take to expand their own interests or to make connections between their interests and the interests of others. For example, one of Cunningham’s clients with autism listens to a niche kind of electronic music. She has explained to him that he might not be able to find other people who listen to that exact music, but he can seek out people who like music that is similar.

After learning to start a conversation, the group moves on to how to maintain one, focusing on elements such as listening and having an equal exchange of information rather than doing all the talking or asking question after question. Participants also learn how to use humor in a conversation, how to pay attention to feedback and how to join a group conversation, Cunningham says.

Bullying is another important topic, but the focus isn’t so much on how to cope with it as how to prevent it from happening in the future, Cunningham says. One thing that group members learn is how to distinguish between actual bullying and straightforward feedback that they may get from someone who is annoyed by their behavior.

Cunningham also runs a PEERS group for adults with autism that includes four weeks focused on dating. (Cunningham doesn’t include the topic of dating in her younger groups but not because she thinks participants aren’t interested. Rather, it’s because parents of children with ASD often aren’t comfortable with their kids exploring romantic relationships, particularly when they still aren’t savvy about friendships.) The dating portion of the program focuses on topics such as appropriate ways to engage in flirting and assessing whether another person is interested.

It isn’t uncommon for men with ASD to be perceived as creepy, Cunningham notes, because they don’t typically understand how to read other people’s cues and might continue pursuing someone who is not interested in them romantically. Meanwhile, there are others with ASD who, despite their desire for a romantic relationship, won’t engage with anyone because they can’t tell if the other person is interested, she says.

Other topics the group discusses include how to handle peer pressure and sexual pressure.

Job hunting

Many people with ASD have trouble finding and keeping a job due to several factors, including a lack of social skills, difficulty understanding workplace culture and sensory difficulties that can cause them to become overwhelmed more easily. However, Smigiel believes that the most significant factor keeping those with ASD from career success is a lack of support.

In essence, Smigiel says, career counseling for those with ASD is similar in spirit to providing career counseling to any other client — it is a matter of finding out the client’s strengths and weaknesses. Smigiel did her internship at a vocational services agency that provided job counseling for those with ASD and intellectual disabilities. The agency helped clients practice their interviewing skills and assigned them a job coach who would try to connect them with positions that matched their skill levels.

Smigiel has worked with people on the high end of the autism spectrum who have found their niche in computer work, but at the vocational agency, they tried to match all clients, including those on the lower end of the autism spectrum, with jobs. “I’m a firm believer that anyone can have meaningful activity,” she says.

The key is to play on the focused nature of those with ASD. “What are they obsessed with?” Smigiel asks. “What can I do with that?”

For instance, Smigiel says the agency had many clients with ASD who loved to clean, so the vocational center helped them set up a car detailing program. The clients’ attention to detail produced “the cleanest cars you ever saw,” Smigiel says.

Counselors working with people with ASD have to think creatively and find that person’s niche, says Smigiel, who believes that everyone on the spectrum possesses strengths. For instance, some clients might be obsessed with organizing, which might make them a good fit for working in a clothing store and keeping all the displays in order.

Clients with ASD also often need help retaining their jobs because they don’t necessarily understand the social skills involved in working with others. As a result, they might ask too many questions, not understand what is and isn’t appropriate to say to a boss or have trouble interacting with co-workers, Smigiel says. In more severe cases, people with ASD might have poor personal hygiene, neglecting to brush their teeth or take a shower either because they don’t see it as a need or because it creates a disturbing sensory sensation for them.

At the vocational center, staff members would provide lessons on the importance of brushing teeth and taking showers, Smigiel says. When teaching these kinds of lessons, counselors should be aware that people with ASD are forthright and won’t want to do something “just because,” Smigiel says. Instead, the staff would say, “You need to take a shower because, otherwise, you’ll smell,” and, “You need to brush your teeth because, otherwise, you’ll get cavities.”

Emotional regulation

Clients with ASD also need help acquiring the self-regulation skills to cope with stress and frustration on the job, says Jamie Kulzer. An LPC in the Pittsburgh area, Kulzer helps clients with ASD and other cognitive disabilities as part of a multiweek vocational training program that teaches cognitive, self-management and vocational skills. The program includes internships with local businesses.

“We have found that emotional regulation is really important because if you’re escalated, [you] can’t access the other resources that you have to deal with problems.”

The program has participants envision an emotional thermometer, with green representing a calm, rational state and red representing a state of extreme sadness, anger or excitement. When individuals are in the red, they are unable to make good decisions, so Kulzer teaches clients to monitor their thoughts and behaviors and to be vigilant to when they are in the “yellow.” She also teaches clients to practice techniques such as deep breathing, visualization or standing up and stretching to help themselves avoid going from yellow to red.

Once clients have returned to a green state, they can approach a problem by asking for help or by using a divide-and-conquer strategy that breaks problems down into smaller, more manageable pieces. They can also express their problem by using “I” statements, such as “I need” or “I don’t understand,” explains Kulzer, an ACA member and assistant professor in the clinical rehabilitation and mental health counseling program at the University of Pittsburgh.

Program participants also learn about the physical and emotional gas tank, which is a measure of mental and emotional fatigue, Kulzer says. A full tank enables the client to be fully alert, present and ready to take in new information. An empty tank makes the client susceptible to aimless daydreaming, flooding emotions, racing thoughts and frustration.

Clients are taught that they can help keep their gas tanks full through self-care measures such as healthy eating, drinking water regularly and getting enough sleep. Kulzer also teaches program participants to approach their work or other projects by breaking them down and doing the easiest parts first and making sure to take frequent breaks.

It is critical for clients with ASD to monitor their physical and emotional gas tanks and to take action when they feel themselves getting to half full, Kulzer says. This means stopping and asking themselves, what’s draining the tank? For one person, it might be staying up too late to play video games, which requires better self-management. For another, it might be the result of being in an overly stimulating environment and needing to take a break by briefly leaving the area, Kulzer says.

In anticipation of the second half of the program, participants work on their vocational skills, which includes an emphasis on general communication. For instance, clients are taught to use “I” statements to talk about their feelings and encouraged to repeat back any request made to them to ensure that they are hearing it correctly and are aware of the nonverbal messages they are sending, Kulzer says.

People with ASD often have difficulty looking others in the eye, which can mistakenly give others the impression of disinterest. Kulzer’s program teaches these clients to say things like, “Eye contact is difficult for me, but I am listening.” Clients are also encouraged to indicate their attention and willingness to work by sitting up straight and taking out their earphones, Kulzer says.

The group also talks about social interaction. Subjects include what is appropriate to discuss in the office and how office friendships can have pros and cons. For instance, although it may be great to have someone you like and get along with, if you favor that person and don’t treat everyone equally while working, it can result in hurt feelings and misunderstandings.

Kulzer also talks with group members about issues such as scheduling and making decisions independently without telling a supervisor. She uses the example of someone with ASD who takes a bus that gets them to work 15 minutes early and then assumes this means that they can also leave 15 minutes early. Kulzer explains to group members that they can’t change their schedules (or make other similar decisions) without first discussing possible options with their boss.

The group participants receive feedback from Kulzer and other instructors as they work in their internships. Together, they tackle problems that come up in the workplace and implement suggestions for improvement. Kulzer says that many of the group’s members go on to pursue associate degrees or certificates in their internship field.

 

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Additional resources

To learn more about the topics discussed in this article, take advantage of the following select resources offered by the American Counseling Association:

Counseling Today (ct.counseling.org)

Practice briefs (counseling.org/knowledge-center/practice-briefs)

  • “Autism Spectrum Disorder” by Carl J. Sheperis, Darrel Mohr and Rachael Ammons

 

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Laurie Meyers is the senior writer for Counseling Today. Contact her at lmeyers@counseling.org.

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 survivors of human trafficking

By Lamerial McRae and Letitia Browne-James October 9, 2017

Millions of human trafficking victims exist across the globe. In the United States, hundreds of thousands of victims experience trafficking. As society expands and evolves, human trafficking perpetrators find new ways to recruit and victimize others. The evolution of perpetration ensues because of increases in accessing technology, shifting state and federal laws, and changing criminal investigation methods within communities. Human trafficking continues to evolve into a new way of enslaving human beings, stripping individuals of basic rights and freedoms, while skirting the legal issues of slavery and ownership.

Human traffickers often recruit individuals by offering the fantasy of increased happiness, stability, relationship success and financial freedom. Human traffickers, often referred to as “pimps” or “playboys,” may recruit a female or male victim with promises of a better quality of life, including, but not limited to money, security and safe shelter. These perpetrators often present as charming and recruit their victims using lies and manipulation. They prey on victims from vulnerable populations, including those with low socioeconomic status (SES), biological females, children and adolescents, immigrants and LGBTQ+ youth. The fact that these vulnerable populations often remain dependent on others or experience institutionalized marginalization allows for perpetrators to paint the picture of a better life, both in terms of finance and social support. Thus, counselors must understand the cycle of perpetration and victimization to pinpoint potential victims among clients.

As a starting point, counselors must understand the nature of the phenomenon and seek ways to identify potential risk and protective factors. Counselors must learn to assess and address possible victimization with effective rapport building and intervention. For example, youth may display delinquent behavior (e.g., truancy, sexual misconduct, drug use) as a symptom of coercion and threats by a perpetrator. Perpetrators often experience greater ease when recruiting teenagers because of their tendency to be influenced by others. Sadly, when teenagers fall victim to a human trafficker, they are subjected to the victim-blaming phenomenon.

Thus, to build therapeutic rapport from a nonjudgmental framework, counselors need to understand the true source of teenagers’ behavior rather than labeling them as inappropriate or delinquent. As counselors increase their understanding of risk and protective factors, the profession may be able to conceptualize human trafficking as a systemic problem from a broad perspective.

 

Risk and protective factors

Several risk and protective factors exist for those falling victim to human trafficking. Risk factors include the following demographics and experiences. Risk factors, which are not limited to the list provided, may change over time with the help of counselors.

  • Low SES
  • Previous or current substance abuse
  • Social vulnerability (e.g., children, females, LGBTQ+ individuals)
  • Limited education.

Protective factors, referred to as strengths in counseling, include the following demographics and experiences. Counselors must foster protective factors and strengths in clients to reduce the risk of falling victim to trafficking.

  • Education
  • Family stability
  • Strong social support networks
  • Mental and emotional health

Counselors should understand these risk and protective factors to assess potential risks for human trafficking and to focus on increasing protective factors in counseling. For example, counselors may use a family counseling approach when working with survivors to increase their connections to loved ones and family. Throughout the process of recruiting and selling human trafficking victims, counselors may notice several risk and protective factors playing a role in the process.

 

Human trafficking business model and counseling implications

Human trafficking remains a mysterious and misunderstood phenomenon. Because of a lack of understanding about the effects of human trafficking on our society, counselors are charged with educating themselves to best address and assess individuals for victimization.

Counselors should recognize that survivors of sex trafficking require additional techniques (to those used with other clients) to build rapport with them and to reduce the mistrust that they commonly have about people. To best serve survivors, treatment approaches need to remain centered on survivors, empower them, provide safety and involve a multidisciplinary approach. In addition, professional counselors working extensively with sex trafficking survivors hold legal and ethical responsibilities to provide appropriate services and identify strategies to overcome barriers to their treatment, including specialized and intensive training.

To begin, counselors must understand the human trafficking business model to conceptualize the systemic issue and the moving parts that contribute to the continuing cycle. To highlight some of the societal and professional impacts, consider the parallel of the human trafficking business model to the process of manufacturing goods. The human trafficking business model includes the following stages of grooming and distribution:

1) The supplier recruits the victim.

2) The manufacturer grooms the victim.

3) The retailer determines price and then markets the victim.

4) The retailer sells and the consumer purchases the victim.

The human trafficking business model is a sophisticated process, not always linear in nature, and it functions as a well-established industry. Thus, the need exists to explore each of the model to better understand how to help victims and break the cycle.

Stage 1: Supplying victims. The supplier, also known as the initial human trafficking perpetrator, displays high levels of mental health concerns (e.g., antisocial personality traits) and shows little concern for the basic human rights of others. When victims enter this stage, counselors may find that these individuals report troubles at home, low SES, depression, anxiety and truant behavior. These factors contribute to their need to survive. Unfortunately, this may result in a perpetrator using charm or manipulation to attract the victims. Perpetrators remove victims’ identification, passports and other valuables to trap them in the world of human trafficking.

Clinical assessment is vital at this stage and remains an ongoing process. Counselors may want to ease survivors into telling their stories, paying special attention to the therapeutic relationship. Thus, the most valuable interventions at this stage include active listening and reflection. When administering specific assessment instruments, counselors will want to measure attitudes about victimization and perpetration and prevalence rates of violence. Counselors must use both open- and closed-ended questions to directly address potential victimization. Nonverbally, counselors will want to avoid direct eye contact and limit their use of touch because of victims’ trauma and abuse history.

Stage 2: Grooming victims. This stage involves moving human trafficking victims from the supplier to the manufacturer. Perpetrators continue to display high levels of antisocial behaviors and major mental health concerns; survivors present with mental health concerns such as depression, anxiety and addiction. Substance abuse concerns usually present when perpetrators force their victims to engage in substance use to coerce and control their behaviors, often resulting in addiction.

Counselors must use clinical assessment and maintain that ongoing process. In addition, because survivors have been manufactured as a human trafficking product, their levels of abuse and mistrust often appear high when they present to counseling. Therefore, counselors must focus on the therapeutic relationship as victims provide information about their experiences in trafficking. Counselors should pay special attention to reducing the stigma of substance use and mental health concerns, especially considering that victims develop these concerns because of coercion and violence.

Stage 3: Marketing victims. This stage involves moving survivors from the manufacturer to the retailer. At this stage, human trafficking perpetrators focus on the marketing and sales aspect of their exploitation. For example, based on the quality of their goods (i.e., victim age, appearance) and market demand, perpetrators determine the price for selling each of their victims. At this stage, survivors present with major depressive, dissociative and addiction disorders.

At this stage, counselors again use clinical assessment to understand the survivor’s story while maintaining a trustworthy therapeutic relationship. As previously stated, severe mental health concerns present because of the violence and abuse that victims experience. Thus, counselors need to use evidenced-based practices to treat depression and dissociative symptoms. Some of the most helpful interventions to treat these mental health concerns include grounding and relaxation techniques.

When focusing on grounding, counselors must engage the client’s physical world to assist the person in becoming present in the moment. For example, counselors may ask clients to locate an object in the room and provide an in-depth description. Relaxation techniques to practice include deep breathing and mindfulness meditation. Both types of techniques allow clients to practice coping skills during sessions that can translate to their everyday life experiences.

Stage 4: Selling victims. As retailers push survivors toward the consumers, the perpetrators continue to focus on marketing strategies and targeting potential consumers. Perpetrators often target large events (e.g., the Super Bowl, national political conventions) to take advantage of the crowds and high demand for paid sexual services. Those paying for the sex services, the consumers, exhibit low levels of depression and anxiety. These consumers often report avoiding relationship concerns or other mental health concerns, resulting in a desire to seek out sexual activity.

Because survivors have been a part of ongoing abuse and a cycle of victimization that they cannot break, counselors must use a systemic approach to providing services. For example, counselors need to provide information on shelters and building connections with family. Counselors may incorporate the use of technology and location services, safety words and discussing location with loved ones at all times.

 

Case example         

Toney, an 18-year-old multiracial, cisgender male, moved away from his caregivers’ home about one year ago and currently lives with a friend. He moved because of safety issues in his home and within the nearby neighborhood. When Toney was 16, his father died during a gang-related shootout at their home. Thus, Toney often felt afraid of engaging in a similar lifestyle and enduring similar consequences. Toney’s mother suffered from a severe substance use disorder that led to eviction from their rental home because she could not afford the rent. Toney and his mother became homeless.

While Toney was homeless, Kevin, a childhood friend, suggested that Toney come live with him temporarily as long as Toney obtained a job and contributed to the rent and utility bills. One day, Toney answered the front door, and a young adult male appearing to be about Toney’s age attempted to sell him a magazine subscription. Toney disclosed to the salesman that he was financially strapped. The young man told Toney about the large sums of money he made while selling magazine subscriptions and offered to put him in contact with the owner. Toney was intrigued by the idea of alleviating his financial troubles, and the young male immediately scheduled a meeting with the owner for later that night.

That evening, Toney met with the young salesman and the business owner in an abandoned parking lot, bought their sales pitch and decided to go to work. The business owner told Toney that he would need to move six hours away to another state because there was a high demand for work there and he would not have to pay any rent or utility bills. The business owner promised Toney the opportunity to travel and see many areas of the country while working in the job.

Thus, Toney left a day later to live in a weekly hotel in a new city with his new manager and several others. Upon arriving, the manager took them to a warehouse to pick up the product. They all began working the next day.

After a few weeks, Toney began grasping the reality of his situation. The job of trying to sell magazine subscriptions was strenuous and exhausting. He often worked 10- to 12-hour days while receiving limited rest and food. When Toney voiced concerns about the number of work hours he put in each day, his manager threatened him. The threats later escalated to physical assault when Toney again voiced his concern and when the manager perceived him to be underperforming at the job.

No matter how hard Toney tried, he could not meet the daily sales goal that the manager set for employees. When Toney failed to meet the daily sales quota, the manager either denied him his nightly meal or forced him to sleep outside of the hotel on the streets. As a result, Toney rarely ate and often did not receive the money he had earned while working. He was told that he would receive the money once the team had completed its sales goals for the area and had moved on to another city.

One day, while trying to sell magazines to a homeowner who declined to buy anything, Toney became agitated and started crying. He told the homeowner that he was in trouble and begged her to help him get home, across state lines. The homeowner had recently watched a documentary on human trafficking and invited Toney to use her phone to call the authorities.

The police arrived and took Toney’s statement about his work experiences. Fortunately, the responding officer had recently attended a departmental training on human trafficking, and she took Toney to the police station for further questioning and support. The officer connected Toney with a local nonprofit organization that provided multidisciplinary services, including professional counseling, to survivors of human trafficking. The organization offered shelter and provided Toney with career development services to help him obtain legitimate work. The shelter’s ultimate goal was to move Toney back to his hometown.

In counseling sessions with Toney, the counselor focused on direct questions to assess the nature of the human trafficking Toney had experienced. For example, “Did anyone threaten you or your loved ones?” and “Did you have difficulty leaving the work that you did selling door-to-door merchandise?” While initially reluctant, Toney eventually responded with answers that indicated his victimization. For example, he reported that his manager used threats and power and control tactics (such as denying Toney food, money and shelter) to force him to work.

Following assessment, Toney received counseling services focused on recovering from the abuse he had endured. Toney felt validated because he was not alone while accepting that he had fallen victim to human trafficking. The counselor and Toney focused on crisis intervention and stabilization in the beginning, which included discussions about adjunct services and basic needs assessments (e.g., food and clothing, job obtainment). Next, the counselor and Toney addressed the trauma, focusing on decreasing anxiety-provoking cues and scaffolding into addressing more severe cues and triggers. All the while, Toney and the counselor developed several grounding and relaxation techniques to use both in their sessions and in Toney’s real-world experiences.

One of the most valuable grounding techniques made use of a rock that Toney could hold whenever he felt distressed. The counselor taught Toney how to become present, while holding the rock, through discussions about the texture, shape and weight of the rock. Discussing these tactile experiences allowed Toney to focus on the here-and-now rather than attempting to escape feelings and thoughts.

Toney and the counselor also used a breathing method in which Toney would take a deep breath through his nostrils for at least three seconds and exhale through his mouth for three seconds. They determined that he needed to take at least three deep breaths during the exercise so that he could calm down.

In the final stages of counseling, Toney and the counselor developed an action plan to help him avoid falling victim to trafficking. That does not mean, however, that Toney took responsibility for the actions of others. Toney and the counselor reviewed the different needs he may have and how to meet those needs in a helpful manner.

While focusing on the trauma from human trafficking victimization, the counselor worked with Toney on obtaining a job at a local fast food restaurant. They chose this restaurant so that he could easily transfer to another store in his hometown once he felt comfortable with the transition. After three months, Toney finally returned home and moved back in with his friend, Kevin. He remained employed as a fast food line cook and began seeking education at a local culinary institute.

 

 

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Lamerial McRae is an assistant professor at Stetson University and a licensed mental health counselor in Florida. Her research and clinical interests include counselor identity development and gatekeeping; adult and child survivors of trauma, abuse and intimate partner violence; marriages, couples and families; LGBTQ issues in counseling and human trafficking. Contact her at ljacobso@stetson.edu.

Letitia Browne-James is a licensed mental health counselor, clinical supervisor and national certified counselor. She is a clinical manager at a large behavioral health agency in Central Florida and is in the final year of her doctoral program at Walden University, where she is pursuing a degree in counselor education and supervision with a specialization in counseling and social change. She has presented at professional counseling conferences nationally and internationally on various topics, including human trafficking.

 

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