Tag Archives: Children & Adolescents

Children & Adolescents

Supporting transgender and gender-expansive youth

By Cortny Stark July 29, 2022

Transgender and gender-expansive (TGE) children and youth continue to experience marginalization, as institutions across the United States institute new oppressive policies that challenge and, in many cases, altogether prevent access to gender-affirming health care. TGE children and youth include young people between ages 3 and 17 whose gender identity is different from the sex designated at birth; the label “transgender” implies alignment with the gender binary (e.g., “I was designated female at birth and am a transgender man”), whereas gender-expansive identities do not align with the gender binary (e.g., “I was designated female at birth and am nonbinary — meaning that I am not a girl or boy”).

The realities of living as a TGE child or youth in today’s social, legal, educational and health-related environments are harrowing. Every day, new policies and legislation are introduced regarding TGE youth’s rights to access medically necessary gender-affirming health care, present as their authentic self at school, participate in extracurricular programs and sports, and have their appropriate name and pronouns honored in educational spaces.

As the parent of an incredible 12-year-old TGE child, my tolerance for the headlines is waning. I wake up each morning and check the latest news, and suddenly, I feel anxiety rising in my chest. I feel breathless and sick to my stomach. I have to put down my device and find a comforting television show or familiar rerun to watch before continuing with my day.

But we can do something about it. As helping professionals, we have an ethical obligation to support members of this community, as well as their caregivers and loved ones, and to advocate for dissolution of oppressive policies and legislation.

The current crisis

Despite over a decade of research and clear medical guidance supporting the efficacy of affirming social and medical interventions, several state and local governments across the United States have initiated anti-TGE legislation. In April 2022 alone, more than 20 pieces of legislation targeting the rights of TGE persons were introduced across the country.

On April 20, the Florida Department of Health released guidance on the treatment of gender dysphoria for children and adolescents, which states: “social gender transition should not be a treatment option for children or adolescents” and “anyone under 18 should not be prescribed puberty blockers or hormone therapy.” Alabama enacted a similar prohibition on affirming health care, but with more severe consequences for providers who violate the ban. The Vulnerable Child Compassion and Protection Act, which took effect May 8, states that health providers who provide gender-affirming puberty blockers or hormones will be charged with a Class C felony. Sanctions for violating the ban could include 10 years in prison or $15,000 in fines.

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Standards of practice from the American Academy of Pediatrics and World Professional Association for Transgender Health, however, continue to support social and medical transition as a necessary option for the health and well-being for many TGE youth.

Earlier this year, Texas Attorney General Ken Paxton issued an opinion stating that gender-affirming medical interventions, referred to as “elective sex changes,” are part of a “novel trend” and “constitute child abuse.” The fact that this opinion equates gender-affirming care with “child abuse” is of particular importance for helping professionals because this means credentialed providers are legally obligated to notify child protective services within 48 hours of learning that a minor is receiving gender-affirming medical care.

Many families and caregivers of TGE youth in Texas are now unable to access medically necessary gender-affirming interventions, such as puberty blockers and hormone replacement therapy. In addition, major TGE advocacy organizations are encouraging families and caregivers of TGE youth to maintain a “safe folder” — a collection of documentation that debunks the “affirming care is abuse” myth. The folder includes “carry letters,” which are documents written by licensed counselors, helping professionals and/or pediatricians who have worked with the youth. These letters contain the professional’s credentials, their relationship to the youth, a statement from the American Academy of Pediatrics supporting gender-affirming medical interventions as evidence-based and best practice, and an overview of the youth’s gender identity development process.

A call for advocacy

I share these current events not to stir your compassion but to make a request: Please act and advocate for TGE youth. You can pursue positive change in whatever realm you hold power, privilege or space. As a professional, I wear many hats, including assistant professor, mental health and substance use counselor, rehabilitation counselor, training facilitator and advocate. These professional roles provide a space for me to channel my anxieties and distress over these recent oppressive policies targeting TGE youth and work toward positive change.

For me, advocating for this population serves as a source of nourishment and a way to derive meaning from what feels like hopeless circumstances, and I hope that engaging in this work may do the same for my colleagues. Here are some ways helping professionals can better support the advocacy efforts for the TGE community:

  • Use a humanistic lens when working with TGE children and youth and recognize the client as the expert on their own experience.
  • Get to know the standards of care and research regarding evidence-based care with TGE youth. And make sure the research you consume and the information you share with others all come from prominent and reliable scholarly sources.
  • Elevate the voices of TGE youth. If you work with this population, know what prominent TGE community organizations provide safe and brave spaces for TGE youth, and be prepared to share this information with your clients. If you facilitate trainings or educational opportunities for responsive and competent practice with the TGE community, and you yourself are not a member of this community, use panels of TGE folx to share their experiences and expertise.
  • Inform people that gender-affirming social and medical interventions are medically necessary and are a key component of suicide prevention. According to a 2009 report by Caitlin Ryan, the director of the Family Acceptance Project, TGE children experiencing caregiver or family rejection are more than eight times as likely to have attempted suicide and nearly six times as likely to report high levels of depression than TGE youth who were not or only slightly rejected by their parents and caregivers. This report also found that TGE youth who were in accepting homes, with caregivers who supported social and/or medical affirming interventions, had rates of anxiety, depression, and suicidal ideation and attempts similar to their cisgender peers.
  • Advocate with and on behalf of these youth in their living environments, schools and greater communities; this may include educating others about the role of affirming health care in preventing suicide and improving TGE youth’s overall health and well-being, testifying against oppressive anti-TGE legislation, or supporting affirming legislation.
  • Honor the history of TGE communities by acknowledging the role of colonization and historical trauma in the erasure of histories of gender diversity. Recognize the systemic influence of adverse experiences in health care, schools, the legal system and other institutions on TGE individual’s ability to trust institutions. This history along with the major influential events in the lesbian, gay, bisexual, transgender and queer (LGBTQ+) rights movement are key to understanding the intergenerational trauma and resilience of members of TGE communities.
  • Keep learning! Developing one’s ability to provide culturally responsive care requires lifelong education and reflective practice. Sign up for workshops and continuing education regarding serving TGE individuals. And join consultation and supervision groups that focus on providing care to this population.
  • Connect and advocate. Connect with a local TGE advocacy organization and volunteer to support their efforts; if time does not allow for this level of engagement, consider donating to these causes to support their advocacy work.

As LGBTQ+ advocate, actress and film producer Laverne Cox once stated, “Each and every one of us has the capacity to be an oppressor. I want to encourage each and everyone of us to interrogate how we might be an oppressor and how we might be able to become liberators for ourselves and for each other.” At this point in history, it is critical that we as helping professionals identify how our actions contribute to the oppression of our TGE clients and do better. The health and well-being of an entire generation of TGE youth need helping professionals who are willing to use their power and privilege to elevate their voices and serve as liberators.

 

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Cortny Stark

Cortny Stark (she/her/hers) is an assistant professor and the substance use and recovery counseling program coordinator in the Department of Counseling and Human Services at the University of Colorado, Colorado Springs. She is also a telehealth therapist with the Trauma Treatment Center and Research Facility, where she provides trauma reprocessing and integration, clinical services for substance use and process addictions, and support for transgender and gender-expansive youth. Her research focuses on LGBTQQIA+ issues in counseling, integrative approaches to trauma reprocessing and integration, and substance use and recovery.

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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 Connoisseur: Nature therapy and brain science in children

By Cheryl Fisher April 20, 2022

Alfred Adler purported that all behaviors have a purpose. Behaviors are often the way the body responds to life’s stressors, especially for children. Yet, many therapeutic treatments for children focus on the modification, remediation and even elimination of a behavior without addressing the underlying cause. This approach suggests that once a behavior is corrected, the child will experience general wellness.

Brain science, however, indicates that the physiological state of children must be attended to before one addresses behavioral change. In Beyond Behaviors: Using Brain Science and Comparison to Understand and Solve Children’s Behavioral Challenges, Mona Delahooke, a licensed clinical psychologist, argues, “When we see a behavior that is problematic or confusing, the first question we should ask isn’t ‘How do we get rid of it?’ but rather ‘What is this telling us about the child?’”

Therefore, behavior is adaptive and a response to the internal and external experience of the child.

Autonomic response refresher

The human body responds to perception of threats to safety by creating a biochemical and physiological state prepared to move the body to fight, flight or freeze. In this state, the body increases the production of adrenaline, norepinephrine and cortisol. The amygdala and the limbic system become activated and temporarily lead brain functioning over the prefrontal cortex, which is responsible for higher order thinking and executive functions. The child is now functioning in survival mode, and the child’s behaviors may manifest in a variety of ways, including distraction, withdrawal, irritability or fidgeting, fearfulness, regression, and aggression.

Rather than blindly rewarding or punishing the child’s behaviors, neuroscience suggests that we seek out the cause of the behaviors before addressing them. It begs us to answer the questions, “Why is the child acting this way? Is the child perceiving a threat to safety?”

As I have addressed in my book Mindfulness and Nature-Based Therapeutic Techniques for Children, counselors must consider if the child is functioning from an underdeveloped kinesthetic system (our sense of our body in space) or vestibular system (associated with the inner ear and balance) resulting from lack of free-form movement. So much of children’s time is spent sitting at their desks or in front of devices, or in structured activities. They lack nondirected, unstructured play and movement. What is the underlying cause? How is the behavior serving to protect the child? Most important, how can we, as counselors, help the child resume a sense of safety and balance and experience a calm and alert state?

Brain science

Several models have emerged over the past few years that emphasize the role of the physiological state of children when treating their behaviors. All these models assume that the behaviors are an attempt to cope with internal or external stressors.

Stephen Porges, the founder of polyvagal theory, proposes that mammals have two neural pathways. The first, the social engagement state, is accessible when the child feels safe and can trust the environment, promoting a calm state accompanied by prosocial behavior. The second pathway is engaged when the child feels unsafe.

Porges introduced the term neuroception to describe the body’s way of scanning the environment for threats to safety. At times, the body miscalculates the risk of safety. According to Porges, the symptoms of faulty neuroception are translated to psychiatric labels and disorders. In other words, a child who has experienced trauma may have a vulnerable nervous system that detects threats that do not exist. Resulting behaviors may include hypervigilance, insomnia, paranoia, bedwetting or a host of other regressive or safety-seeking responses. On the other end of the spectrum, the child may ignore actual risks in the environment, resulting in greater threat to self and psyche.

Therefore, based on neuroscience, Porges recommends providing children with individualized cues of safety that allow social engagement behaviors to emerge spontaneously. According to Porges, three situations must be present to feel safe. First, the autonomic system must not be in a defensive state (fight, flight or freeze). Second, the social engagement system must be activated, which results in the downregulation of the sympathetic nervous system and promotes prosocial behavior. Finally, there must be cues for safety (vocalizations, gestures and positive facial expressions) detected via neuroception. The assumption is that cues for safety can only be exhibited and detected in human-human interaction. However, research continues to support that human and more-than-human interactions also afford meaningful connection.

Brain science and nature

Engaging in the natural world has long been known to have a calming effect on the body. A biochemical exchange occurs in the natural world that results in by-products that, when inhaled or absorbed by the human body, produce a calm and alert state. The earth’s core is like a battery that emits negative ions. Blue spaces (oceans and waterways) offer ionic by-products. Additionally, green spaces (forests and parks) produce phytoncides and terpenes.

Fifteen to twenty minutes of being in a natural setting affects the body by decreasing cortisol, norepinephrine and adrenaline (hormones released when the body perceives threat); increasing serotonin; and reducing blood pressure and respiratory rate. The body responds to the natural space by engaging the relaxation response. Additionally, the immune system is enhanced by both an increase in number and activity of natural killer cells. These effects are sustained for up to a week following single exposure to forests and as long as a month following two days of engagement in green space.

David Clode/Unsplash.com

The earth communicates through the production of these chemicals, and the human body responds to many of the messages (safety cues) by reducing the body’s defensive state, activating the social engagement system and promoting homeostasis (i.e., a calm and alert state).

Research is conclusive that children who engage in natural settings experience greater well-being, are calmer and demonstrate more prosocial behavior. For example:

  • In their article “The role of urban neighbourhood green space in children’s emotional and behavioural resilience,” Eirini Flour and colleagues found that children impacted by poverty and living in urban settings experience improved emotional well-being when exposed to neighborhood green space.
  • Diana Younan and colleagues noted in their article “Environmental determinants of aggression in adolescents: Role of urban neighborhood greenspace” that exposure to greenspace within 1,000 meters surrounding residences is associated with reduced aggressive behaviors in youth.
  • Andrea Faber Taylor and Frances Kuo discovered that, in general, children who play regularly in green play settings are calmer and more alert than children who play in concrete outdoor and indoor settings. Their study, “Children with attention deficits concentrate better after walk in the park,” also found that children with attention deficit/hyperactivity disorder who play in green open areas versus areas with trees and green grass show milder symptoms.

Although it is becoming increasingly important to integrate outdoor activities into clinical practice, routine access to green and blue spaces may be hindered by many factors. In this case, we turn to indoor alternatives.

Nature therapy indoors

Ecotherapists are capitalizing on the research by integrating nature-informed practices and activities into their work. My own research examines the use of nature-informed sensory “time-out/time-away” stations in the emotional and behavioral regulation of school-age children. Historically, time-out has been used to remediate unwanted behaviors in children. This often involves using a corner of a room without windows or distractions. Once the child has calmed down, they may return to the group setting.

However, if (as Adler suggests) all behaviors have a purpose, then the child has learned only that the presenting behavior is unacceptable and to suppress their natural response to whatever triggered it. They have not learned to self-regulate and address the underlying emotional or physical state.

A nature-based sensory time-away station, however, is imbued with items such as plants and herbs that emit terpenes. The station may have a tabletop sand garden that provides tactile exposure and promotes mindfulness. Additionally, nature soundtracks may play in a headset to allow the brain to register these soothing frequencies.

The preliminary data continue to demonstrate that children are able to use this time-away station as a self-regulating tool to allow for the relaxation response, calming of the amygdala and engagement of the prefrontal cortex. Children engage with the natural material, feel more grounded and (depending on developmental stage) are better able to articulate their underlying state verbally or through expressive arts. They return to their previous activity feeling calm and alert.

Here’s some advice on how to create and introduce a nature-based sensory time-away station:

  • Create the station. A nature-based sensory station may be created indoors or outdoors. It includes physical elements that engage the senses. Items may include edible plants and herbs to promote exposure to terpenes. Cotton balls soaked in essential oils also can provide exposure to terpenes through smell. Small containers of rocks, sea glass, pinecones, feathers and shells can provide the child with different tactile experiences. A small tabletop sand garden with miniature rakes can be purchased or created for a tactile and mindful activity. A betta fish or small fish tank may also add biodiversity to the space. Nature sounds can be streamed through headphones. Additionally, paper and tools to write, color or paint may aid in the communication of triggers once the child begins to enter a calmer state. And items can be rotated to capture seasonal changes to your nature-based sensory station.
  • Introduce the station. Because this is a novelty, everyone in a group setting such as a classroom will want to play at the station. It is important to allow each child a chance to explore the space. Using a timer, have children take turns engaging in the station. When the time is up, they may return to the classroom activity. If introduced as a tool, children will soon learn that this space can be accessed to help regulate emotions and behavior in a productive manner. In essence, the children will learn that they feel better after spending time interacting with the space.

In the home setting, the child can help create the space and be taught that it is a place to go to reboot. Show the child how to engage with the multisensory space and then leave them to their own processes.

In addition to the many ecotherapeutic homework assignments and interventions available, counselors utilizing this space as a co-therapist in the field can introduce the benefits of nature-based multisensory engagement and help their clients learn to self-regulate outside of the therapy session.

In conclusion, behavior is a response to interpretation of internal and external stimuli. A child who feels unsafe may experience physiological arousal and respond in a defensive manner. As counselors, we can help educators and parents learn to address a child’s physiological state by creating safety cues for the child. By introducing a nature-based multisensory space, children can learn ways to reduce defensive states, increase homeostasis and activate their social engagement system.

 

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Cheryl Fisher is a licensed clinical professional counselor in private practice in Annapolis, Maryland. She is director and assistant professor for Alliant International University California School of Professional Psychology’s online master’s in clinical counseling. Her research interests include examining sexuality and spirituality in young women with advanced breast cancer, nature-informed therapy and geek therapy. Contact her at cyfisherphd@gmail.com.

 

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

Play (in) therapy: Approaches to working with young children

By Maureen Bissen Neuville December 3, 2021

I do play therapy, but I am not certified nor am I a registered play therapist — although I wanted to be! 

My early counselor training and mentorship was mostly behavioral, but early on I moved to a less didactic and more interactive approach. That, combined with my interest in working with children, drew me to explore play therapy. 

After earning my master’s degree in counseling, I entered a play therapy certificate program. I’d completed most of the classroom credits when the university decided to end the program. I felt such disappointment. This was in the years well before virtual coursework, and it was not possible for me to travel to get internship or supervision elsewhere. Thus, my goal of attaining certification in play therapy was squelched. Instead, I worked for years as a general counselor and developed an expertise in serving youth and families.

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Cultivating skills with youth

Given the lack of opportunity to complete my formal education and certification in play therapy, I moved forward with developing more intentional activities (e.g., drawings, games with therapeutic content) in my counseling work. My sessions with youth of all ages affirmed the value of interactive play and hands-on exercises. Keeping their hands busy and minds engaged enhanced the therapy experience for them. Yet I realized the importance of making sure I was not just offering fun tasks or gimmicks but rather genuine and intentional therapeutic purpose and process. 

For example, playing Uno with school-age clients can help with building rapport, but to make it therapeutic, one could have certain cards associated with directives to share an experience or emotion that is relevant to their treatment goals. There is an abundance of workbooks to use with youth of varying ages to supplement and engage them directly in their therapeutic work. I used many of these workbooks, often adapting tasks and visuals to my therapeutic style and my clients’ needs and preferences, and I also designed my own visuals and interactive work. To make the work more their own, I began having the youth draw or make their own charts and scaling graphs (“Show me however you want to”) rather than doing it for them and just filling in their answers. 

These techniques were certainly not play therapy, but they were part of my evolution as a counselor of youth. Throughout the years, I independently reviewed my earlier play therapy coursework and read additional materials, primarily by Terry Kottman and Garry Landreth, building my sense of professional self within their theoretical constructs.

‘Play in therapy’ or play therapy?

In my years teaching Counseling Children and Adolescents courses in a local CACREP-accredited master’s in mental health counseling program, I encouraged my students to include playful and hand-on activities in their sessions with youth — even with teens. Somewhere along the way, I felt a need to delineate the difference between this approach and true play therapy, so I coined the phrase “play in therapy.”

When the few play therapists in our small city retired, they, familiar with my work, began to send their referrals to me. I took on these young clients, informing their caregivers of my partial training in play therapy (although at the time, almost no other options existed nearby). I added more representational tools (e.g., puppets, a dollhouse) to my work with youth. To provide more continuity for these youth and to deepen my own work, I intentionally moved to a fuller play therapy mindset and approach. 

At that time, I had opportunity to work independently within a certified mental health clinic, and I made the decision to create a separate play therapy room. The importance of having a sizable array of figures became clear to me, as too few tended to limit the children’s expressions. I had read that a minimum of 100 figures was needed and that a few hundred would offer fuller opportunity for expression. This initially surprised me, but I found it to be true. Almost never has a child been overwhelmed by the volume of figures in my room; in those rare instances when they were, I would guide them in a more focused, yet still varied, selection. 

As I expanded my therapy office, I became nearly obsessed with scouring secondhand stores and rummage sales to find miniature figures — a common malady for aspiring play therapists. Miniature figures, when carefully chosen and made easily accessible, offer a world of expression for children, who often create their own metaphors and meaning with them.

I continued to immerse myself in play therapy, reading professional articles and books by both traditional and contemporary authors. My goal was to put play therapy theory and skills fully into practice. One of the big changing points for me was when I consciously began to play less with the child and instead sat with clients while they played. I’m naturally a talker and somewhat directive, but I learned to watch, to listen, to be silent. I observed, reflected and encouraged my young clients. 

More and more, I allowed the child to be in charge, enhancing Eriksonian tasks of autonomy, initiative and industry. I learned to curb my inclination to speak to, move toward and invite the child; instead, I let them come to me. 

Certainly there are times when we as counselors need to be in charge, to have rules and boundaries, and to take the lead to move therapy forward, but I emphasize here Kottman’s Adlerian value (also recommended by Landreth and others) of returning responsibility to the child and empowering them. This helps build a secure relationship in which children can choose to play (or not to play), be themselves and know that you will accept them and meet their needs.

Counseling young children 

Research for my Guided Drawing technique (published in the Journal of Creativity in Mental Health in December 2019) led me to a deeper understanding of early child development and approaches for that population. Familiarizing myself with DC:0-5 Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood and reviewing literature on developmental tasks and trajectories were helpful in assessing, diagnosing and treating my youngest clients. I strongly recommend that child therapists at least view the DC:0-5. Its biopsychosocial focus, which highlights early caregiving, informs us of early developmental inclinations and experiences that affect youth who eventually present to us for counseling.  

While Landreth does not endorse posing questions to children in sessions, many counselors do query their young clients. Adaptations to standard counseling microskills have proved helpful and become central to my work with youngsters. I now reframe my questions into curious statements. For example, rather than asking, “What were you feeling when that happened?” I might say, “I wonder what you felt” (with an emphasis on “wonder” and a clear closure at the end.) This subtle change helps youngsters feel less intimidated, less forced to answer in a prescribed way and gives implicit permission not to answer at all. This question-as-statement approach can also be helpful when wanting to gather information from older youth. 

When I do ask questions, especially of the very young, I typically use cued invitations with a three-choice format: “Were you really scared, kind of scared or not scared?” “Are you worried more, less or the same as you were when Papa was here?” Numerous professional articles support this cued invitation approach as being better than either forced-choice or open-ended questions for young children still in the concrete thinking stage. I suggest this as a starting point at least, with deeper or more specific inquiries coming only after rapport has been established or a need for more specific information becomes evident. These cued invitations, if presented conversationally, generally do not disrupt the flow in a free-play environment.

Play speaks, and we are to listen

My academic preparation included awareness of how patterns and themes emerge and are revealed in children’s play. Patterns of play might include (but are not limited to) orderly, tentative, chaotic or focused (maybe on a certain category of figures) or the acting out of scenes over and over. 

Likewise, the identification of themes can be essential in understanding child clients. Some common themes revealed in ongoing play sessions include family-oriented expressions, nurturing, loss and aggression. Fantasy and make-believe are also common. The counselor’s task is to consider whether this is typical child’s play (for this child at this time) or symbolic of wishful thinking connected to distress in the child’s life situation. Patterns and themes are critical factors to watch and listen for in child’s play because this is the way that children reveal what is in their hearts and minds.

As sessions proceed, it is important to note if there are changes in a child’s play and to consider what those changes might indicate. I have learned to recognize some common themes and to form hypotheses about what those might mean to or about the child (e.g., the child is experiencing anxiety or fear of abandonment). Yet I’ve also learned to give the child time to reveal whether my hypothesis is a fit for them. 

I have been surprised at what children reveal as they engage in representational or metaphoric play. Sometimes their play serves as a disclosure of abuse or distressing events; other times it provides a picture of their worldview and self-concept. 

There is a danger in interpreting every action as projective, however. Sometimes the child’s play is just that — play. Knowing the difference can be challenging. My advice is to keep your hypotheses in mind and to see if patterns support them, while remaining very open to what else might surface in sessions. 

As is the case with all counselor development, skills will improve with experience, especially when we engage in supervision or peer review and as we self-reflect and recalibrate our approaches.

Play therapy

The play therapy space is both literal (the room, child-sized furniture, sand tray, miniatures, etc.) and figurative (the emotional and verbal space created by the counselor). Such a space offers opportunity for children to establish and express their own dominant and recurring ideas. It no longer surprises me, but it still amazes me how children (consciously or not) express their inner selves and make meaning of their life as they process through their play.

Although a counselor can be culturally sensitive while engaging a child with “play in therapy,” I believe that play therapy has the added advantage of being more culturally open because the child sets the stage, selects the figures and, thus, tells their own story. During “play in therapy,” a counselor might choose a particular worksheet or set of figures to demonstrate a concept, but these visuals might not fit a world that is familiar or preferred by the child. 

From the start, I was intentional about including miniature human figures of varying skin tones, but I later added numerous other items to give children the opportunity to represent their own religious, cultural and family traditions and values in their play. Offering myriad toys and miniatures from which children may choose diminishes the inferred bias (even if unintentional) that may occur when a counselor chooses the visual or hands-on tools. 

I have learned to scaffold and support, to delight with clients’ successes, yet also allow them to struggle. I empathize with, even normalize, what they might perceive as failures. Here’s a simple example: A few children have had trouble opening the cover to my sand tray. Resisting the urge to bail them out, I sit and wait, saying, “You are trying to figure out how to open that.” Even as the children’s eyes plead for help, they keep on trying and eventually get it open. I delight aloud in their competence. (I could remove the cover completely, but what opportunity for discovery and mastery.)

I learn much from my young clients by being watchful and responsive. Mirroring can be a powerful technique and happens naturally when the counselor is fully attentive and responsive to the child. I’ve come to realize the value of simple reflections, tracking and restating children’s phrases word for word. 

I also learn from my interns. One amazed and delighted me in her very first play therapy setting. A child arranging animal figures said, “I’m playing a zoo.” The intern responded, “You are playing a zoo.” This literal tracking — word for word, even when not grammatically correct — can sound and feel awkward for many professionals, but this intern got it right away. 

I often explain to parents why I respond in this curious-sounding, almost mechanical way. It’s so the child will know I am listening carefully and that I accept their telling and their verbiage. Children are generally comforted by this. Even so, one child asked me, “Why do you talk that way?” 

My response to the child’s question was, “So you know I’m listening.”

Grasping the difference

Despite play seeming inconsequential, it is an important developmental task and thus highly facilitative when included in a child’s counseling. “Play in therapy” is a valid and effective way to work with youth. Yet true play therapy is not a technique but an integrated way of being with and for the child and has particular purpose. 

Many counselors do not realize the difference between “play in therapy” and play therapy, nor do they know that the latter is systematic and grounded in theory, whether client-centered, Adlerian or other. I encourage all counselor educators to enlighten students about this, even if only to highlight that adding a playful manner or activity to a session does not in itself constitute play therapy. In either approach, as with all therapy modalities, the client-counselor relationship is central to the work. In play therapy especially, the child’s growth comes from the counselor being fully present.

Seeing young children might be within any licensed professional counselor’s scope of practice, but it is not a competency for most. I remind my supervisees, and here my readers, to honestly know and ethically reveal their level of competence. “I use play in therapy” is, I believe, accurate for most counselors who work with youth. 

For me, “I use play in therapy” has evolved into “While I am not certified, I do play therapy.”

 

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Maureen Bissen Neuville is a licensed professional counselor. She has been a therapist, counselor educator and clinical supervisor in La Crosse, Wisconsin, for more than 20 years. She is grateful to be able to continue in the counseling field even as she moves toward retirement. Maureen envies and respects those who have completed play therapy certification or achieved registered play therapist status. Contact her at mneuville@pomcounselingllc.com.

 

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

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

Voice of Experience: Three rules for identifying abnormal child sexual behaviors

By Gregory K. Moffatt November 23, 2021

I explained my symptoms as the orthopedist looked at my knee, and he made a statement that I subsequently borrowed and have used many times in my work since then: “What you are experiencing isn’t normal, but it isn’t unusual.”

In other words, while my knee shouldn’t have been doing what it was, my symptoms were common and not necessarily a problem.

That line is applicable to many things we face as counselors. I have seen literally thousands of children in one forum or another throughout my long career, and I’ve talked to hundreds of worried parents.

“I found my child doing …” they often begin with awkward hesitation and then follow it with some behavior they observed that troubles them. Sometimes I am troubled too, but not always.

The childhood sexual behaviors I see can be grouped into three categories: normal behaviors, behaviors that are not normal but not unusual, and behaviors that are abnormal.

Prior to age 2 or 3, children don’t have any concept of modesty and may disrobe in the middle of Walmart if they are uncomfortable. By age 5, most children are beginning to learn modesty but still might run through the house naked even if company is present. In a way, they think that if they run fast enough, it doesn’t count as being naked.

By prepubescence, nearly all children have learned the family and cultural rules of modesty.

Likewise, nearly all children exhibit sexual behaviors at one time or another. They may self-stimulate, explore their bodies, and if other children are in the home, they might notice, explore or tease about the other child’s body parts.

As with modesty, children must learn how to use their body parts, what parts they can show and what parts they cannot, and what parts on someone else they can touch and which ones are off-limits. Learning these rules takes time and experience.

Parents rarely call me about the normal exploration they see in their children. Most of them recognize common childhood behaviors. It’s more likely I’m called when behaviors fall into the second or third category.

“I saw my 6-year-old child and his same-aged cousin in the bedroom playing. They had taken off their pants and were waiving their penises at each other,” one troubled parent said.

While not normal (not all children do this), this behavior isn’t unusual and by itself isn’t necessarily cause for alarm.

“I came into the bathroom and caught my 8-year-old son holding down his 5-year-old sister and pulling her underwear down while she was yelling at him to stop,” said another parent. This behavior is definitely troubling and falls into the third category.

There are three basic rules for distinguishing between behaviors like the second and third examples above: forced, painful, invasive.

Rule No. 1: Normal sexual behaviors in children are never forced. The exploration is mutual. While one child likely had the idea first, both children must participate. This doesn’t mean that two children might agree to engage in abnormal sexual behaviors, however. Hence the next two rules.

Rule No. 2: Normal sexual behaviors in children are never painful. When children who usually behave normally realize they have caused pain, they stop.

Rule No. 3: Normal sexual behavior in children is never invasive. Normal childhood curiosity does not include inserting objects or one’s own body parts into the cavities of others — anus, vagina, mouth, etc.

There is one other important caveat. Most normal childhood behaviors occur between children of similar age. It is highly unusual for a young child to sexually engage with a teen without violating one of the three rules above. That behavior definitely calls for further investigation. And, certainly, any sexual interaction between an adult and a child is cause for mandated reporting.

Most of the sexual behaviors parents see in the first two categories — normal or not normal but not unusual — are not necessarily behaviors we condone. But just because one of these behaviors happens doesn’t mean there is trouble.

Sexual behaviors are laden with both cultural rules and religious meaning. As a counselor, I must be able to identify sexual behaviors that are common — as well as those that may not be normal but aren’t unusual either — and put a parent’s mind at ease while also respecting their culture and belief systems.

Most importantly, I must be able to identify symptoms of abuse and abnormal sexual development, and I must comply with mandated reporting laws within my state. It was a desire to prevent child abuse and intervene where I could that motivated me to begin my career as a child therapist in the first place.

Andrew Seaman/Unsplash.com

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Related reading, from the Counseling Today archives: “Addressing children’s curiosity of private parts

 

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Gregory K. Moffatt is a veteran counselor of more than 30 years and the dean of the College of Social and Behavioral Sciences at Point University. His monthly Voice of Experience column for CT Online seeks to share theory, ethics and practice lessons learned from his diverse career, as well as inspiration for today’s counseling professionals, whether they are just starting out or have been practicing for many years. His experience includes three decades of work with children, trauma and abuse, as well as a variety of other experiences, including work with schools, businesses and law enforcement. Contact him at Greg.Moffatt@point.edu.

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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.

Suicidality among children and adolescents

By Laurie Meyers August 25, 2021

This past spring, Children’s Hospital Colorado declared a “state of emergency” in youth mental health. Over the course of the COVID-19 pandemic, the hospital system’s pediatric emergency rooms and inpatient units had become increasingly overrun with children and adolescents with serious mental illness, many of whom were actively suicidal.

“It has been devastating to see suicide become the leading cause of death for Colorado’s children,” the hospital’s CEO, Jena Hausmann, told journalists and reporters at a pediatric mental health media roundtable on May 25.

This mental health crisis is not confined to Colorado, however. Pediatric medical systems across the nation have reported a significant and sustained rise in mental health-related visits for children and adolescents that began in spring 2020. According to the June 18, 2021, issue of the Centers for Disease Control and Prevention’s Morbidity and Mortality Weekly Report, mental health-related emergency room visits among adolescents ages 12-17 increased 31% compared with the rate in 2019. In addition, the report found that in this age group, the mean weekly number of emergency room visits for suspected suicide attempts was 22.3% higher during summer 2020 and 39.1% higher during winter 2021 than during the corresponding periods in 2019. This increase was more pronounced in girls; during winter 2021, suspected suicide attempt visits to the emergency room were 50.6% higher among girls ages 12-17 than during the same period in 2019.

polya_olya/Shutterstock.com

A confluence of factors

Research indicates that mental health concerns and suicidality have been increasing in children and adolescents for years. The current crisis cannot be linked to any singular cause, but it is evident that the isolation and anxiety of the pandemic added an accelerant to an already burning flame.

Renee Turner, a licensed professional counselor (LPC) in San Antonio, points to several factors she believes have been detrimental to child and adolescent mental health. Although she declares she is not by any means anti-technology, Turner admits she is concerned about the influence of social media, which not only continues to feed cyberbullying — which, unlike “old-school” offline bullying, is inescapable and omnipresent — but also encourages children and adolescents to view the world through an artificial lens, she says. “Children don’t have the ability to sort out what is real, what’s true,” and many parents are not teaching them how to consume online content in context, explains Turner, a registered play therapist supervisor. Technology is all-consuming, and many parents do not monitor or restrict their children’s screen time.

For that matter, Turner notes, many adults struggle with their own screen addictions. She believes this contributes to another modern problem: attachment issues. The rise of dual-income families, in which parents work demanding hours or multiple jobs for financial reasons or because of career demands, makes it more difficult to find time for bonding, she asserts. 

Turner also considers the pressure of living in such an achievement-oriented society another potential factor in the increase of suicidality among this population. “I see kids who are chronically overscheduled,” she notes. These young people are involved in myriad activities in consistently competitive environments in which achievement is conflated with self-worth, Turner points out. “It’s all [based on] their output, instead of them being valuable for just being them,” she says.

Turner, the director of Expressive Therapies Institute PLLC, has counseled middle school-age children who are already anxious about how they’re going to get into college. The demands on their time are such that they are staying up late into the night to get everything done, she says. What really stands out for Turner is that some of her clients who are in middle school and younger are self-harming and suicidal because they see no end to the treadmill they find themselves on. The COVID-19 pandemic further complicated the situation, she says, because children and adolescents struggled with online schooling even as parents tried to juggle working from home, taking care of the kids and helping with schoolwork. 

Turner stresses that children and adolescents need to have areas of their lives that exist simply for enjoyment — not performance. “If everything is evaluated, everything becomes work,” she observes.

Sarah Zalewski, an LPC who specializes in child and adolescent counseling, was working as a school counselor in a Connecticut middle school at the beginning of the pandemic. She noticed that the coronavirus restrictions had a profound effect on her clients and on students. “The kids who were in virtual schooling and separated from their peers struggled way more than those in school,” she says. “That routine and the connection with their peers is almost like a distraction from the stuff that is going on in their heads.” Things that had been on a “low boil” suddenly flared up, she says. 

Children and adolescents also seemed to struggle with the loss of familiar routines, Zalewski adds. Interestingly, she noticed that students who had been perennially overscheduled before the pandemic had a particularly hard time coping.

Catherine Tucker, a licensed mental health counselor in North Carolina and Indiana who specializes in trauma therapy for children, adolescents and adults, notes that early adolescence (approximately 11 to 14 years) is a particularly vulnerable time. “One of the normal developmental pieces [during early adolescence] is that every generation thinks they’ve invented all the normal problems, such as peer pressure, sex, bullying, dating. They feel like nobody older than them can possibly understand what is happening to them,” she says. As a result, adolescents often feel seen and understood by their peers but not by adults, especially their parents, notes Tucker, an American Counseling Association member and a licensed school counselor at the middle school level. This is a vital source of emotional validation that adolescents have been missing while separated from their peers, she points out.

Tucker also thinks that we’re underestimating the value of physical contact. “Just basic touch; it doesn’t have to be intimate. Just being near other people. The more we find out about neurobiology, the more we learn that things like eye contact, physical gestures and cues can help regulate the nervous system,” she says.

Marginalized populations are at an even greater risk for mental health issues and suicide, and the disproportionate toll of COVID-19 on Black, Indigenous and people of color communities has been an exacerbating factor. Brenda Cato, a professional school counselor who has experience with elementary, middle and high school students, says many of the students at her predominantly Black high school in Augusta, Georgia, saw school not as a social event but as an escape. Most of her clients come from impoverished homes where parents are working multiple jobs and utilities are skyrocketing. At school, these students get two meals a day. Cato believes not being able to get these meals during the pandemic played a significant role in students’ general inability to cope. 

Working with parents

The counselors interviewed for this article contend that educating parents is a vital part of addressing the suicide crisis among children and adolescents. Learning the warning signs of suicide and knowing what to do if a child becomes suicidal is crucial for parents, but it all begins with establishing communication and a sense of trust and safety. “The most important thing is to be able to establish a safe … [environment] where your kid can come and talk to you,” Zalewski says. 

She advises parents to schedule regular one-on-one time with their children. That might involve going out to eat ice cream together or playing games and talking, for example, but she emphasizes that the time should be spent without the parent being on their phone. It is important for children and adolescents to know that they have their parent’s full attention, she says. Zalewski also recommends having regular conversations in which the parent communicates that anything their child tells them in that time or space has no consequences.  

Turner’s clients include overscheduled and single parents who often struggle with the idea that to truly be there for their children, they need more time — time that they don’t have. So, Turner emphasizes quality time to these parents. “It’s essentially meeting the child where they are,” she says. “Taking an interest in what the child is interested in and asking them about that, engaging in their world.” Turner suggests parents have “date nights” with their kids and schedule times when everyone shuts off their phones and puts them in a basket to create a distraction-free zone. 

It can also be helpful to teach parents to establish “bursts” of listening time, Turner says. For example, when a parent is in the middle of something and a child is saying, “Mom, Mom, Mom,” the parent can reply, “OK, I have five minutes right now, so tell me what you need to tell me.” 

Of course, parents may struggle with how to respond appropriately when they find out that their child is experiencing a mental health crisis, especially if the child says, “I don’t want to live anymore.” Zalewski reminds parents that it is important to first take a moment to listen to their child. She then advises parents to say something that lets their child know they are there for them. For example, “Thank you for telling me. That was a brave thing to tell me. Do you want to tell me more about that?”

Zalewski then helps her clients plan for the next steps. “It doesn’t need to be a heavy-handed thing,” she says. Parents can use language such as “We are going to collaboratively figure out what our next steps are. I don’t want you to feel that way, and I want to keep you safe.” The child and parents can then discuss options. 

She adds that parents should ask one crucial question: “Are you able to keep yourself safe?” If the child isn’t sure, she advises parents to say, “I think maybe we need to go to the hospital and see if the counselor there can give us some ideas.” In many states, clients can call 211 to reach appropriate health agencies and even request that a mobile crisis unit come to the home to help establish a crisis plan, she adds.  

But even children and adolescents who have trusting and open relationships with their parents don’t always speak up when they’re experiencing suicidal thoughts. So, counselors need to ensure that parents recognize the warning signs, which are similar to those in adults. “What’s scary is that adolescents can be so much more impulsive than adults, especially … kids who have poor impulse control generally,” Tucker acknowledges. “There are fewer warning signs and fewer opportunities for intervention.”

Tucker emphasizes the importance of educating parents about reducing children’s access to means of suicide, such as having unlocked firearms and medications in the home. 

“The warning signs that I look for are not necessarily different than [those for] adults but are often written off as ‘teenage behavior,’” Zalewski says. For example, withdrawing may be either a warning sign or simply a wish to be alone. Parents should look for major changes in their child’s behavior in areas such as eating, sleeping and socializing, she says. Giving away prized possession is also a major red flag, she adds. 

Zalewski stresses that parents should not dismiss a child’s statement of wanting to hurt or kill themselves. “So many parents have said, ‘I thought this was just them expressing themselves for attention.’ If this is your kid’s way of getting attention, you need to pay attention and find out why they are using those words,” she says. 

Zalewski also urges parents to honor their intuition: “If you think there is a problem,” she says, “there probably is.”

Teachable moments

Cato faced a different kind of challenge when educating parents of students who had been identified as suicidal. “I was working in a predominantly Black elementary school, and a teacher sent a child to me who had been making suicidal comments,” she recalls. After assessing the student, Cato called the grandmother, who was the child’s guardian. The woman was irate and asked how many students in the school had been tested for suicide. Cato reassured the grandmother that the school didn’t test — it assessed. This taught Cato the importance of educating parents on suicide rates and the percentage of children who attempt or die by suicide.  

Cato didn’t approach the situation with the student’s grandmother from the attitude of “your kid is suicidal, and you will get help.” As a parent herself, she knew that if she didn’t understand what was happening with her own child, she would want someone to walk her through it. So, Cato sat down with the grandmother and explained that her granddaughter wouldn’t necessarily be put on medication or need ongoing therapy. However, Cato recommended that the child be seen by an expert. She told the grandmother that the school just wanted to make sure the child was OK and that she wouldn’t harm herself. Cato also reassured her that her granddaughter would not be stigmatized or labeled as a “problem” student, nor would a note be put in her permanent record. “I think everything is about how you communicate with people,” Cato says. Besides, the grandmother’s concerns were understandable, she adds. Black students are commonly — and disproportionately — diagnosed with serious mental health issues, Cato says, adding that she has seen students of color sent to special education classes based solely on disciplinary issues.

After the student was medically cleared, Cato worked with the student to create a reentry plan that included regular check-ins. These were sometimes as simple as walking casually with the child and asking her to rate her day on a scale from 1 to 10.

Cato tries to turn all her interactions with students and parents into teachable moments. She provides them with pamphlets, resources and crisis hotline numbers, and every time she visits a classroom, she reminds students that the counselors and teachers are there for them. She says she tries to “help them to understand it is not abnormal to feel this way.” She purposely uses “we” when she speaks to students: “We’ve all gone through rough times; we all need help sometimes.” 

Zalewski believes it is essential to also point out and honor the resilience strategies that children are already using. If listening to music helps a child or makes them feel better, then it is a good coping skill, she says. Discovering coping strategies helps build children’s confidence, she notes, and she informs parents of their children’s coping strategies too.

For that matter, Zalewski has found that her young clients often love to teach the strategies they have learned in session to their parents. In fact, to encourage clients to practice a skill outside of session, she recommends that they teach their parents how to correctly take a deep breath and explain what deep breathing does to the brain to calm the body. “Because then we’re helping parents regulate, [and] then we are co-regulating,” Zalewski says. “It can also really give a child a sense of self-efficacy that a lot of kids are lacking because kids are inherently powerless.”

She also works with clients on mindfulness, guided imagery, progressive relaxation, and identifying what physical activities they enjoy and why. For example, a child might like to play basketball in the driveway, but in Connecticut, snow often gets in the way. So, Zalewski helps them figure out the source of their enjoyment: Is it the physical energy they’re expending? Is it the repetition? They then come up with alternatives such as using weights in the basement. Zalewski is a firm proponent of anything that can get clients moving and (when possible) outside. “Nature is reparative for most humans,” she notes.

Tucker says that before the pandemic, children and adolescents were already experiencing stress related to a lack of connection, which she thinks could be associated with too much screen time. As children and adolescents begin to return to in-person activities, it is crucial to make sure they strike a healthy balance between screen time and social activities such as playing sports, working on art projects or simply hanging out together, she stresses. She also believes that the currently common practice of banishing recess in favor of test preparation or other extra classroom work has contributed to children’s anxiety levels. She argues that kids need a lot more time dedicated to free play and imagination.

Helping the helpers

Julia Whisenhunt, an LPC and certified professional counseling supervisor, specializes in studying and training others in suicide prevention. She always frames her workshops around suicide data to “help people understand that [suicide] isn’t uncommon.” Her goal isn’t to normalize the idea of suicide but rather to let people know that it happens and there is help. 

“I know there’s an assumption that talking about suicide makes people suicidal, but the research doesn’t bear that out,” notes Whisenhunt, an ACA member who is an associate professor in the counseling department at the University of West Georgia (UWG). “I think it’s the opposite. I’m confident that trainings have saved lives and helped individuals. I know that. I’ve lived it. The suicidality is there — people are just struggling in silence.”

It is important when training people who are not mental health professionals to emphasize that their role is not to “save” an individual who is suicidal but rather to get them help, Whisenhunt adds. 

Although Whisenhunt’s workshops are geared toward college staff (and students in positions of authority, such as resident associates), she is trained in Applied Suicide Intervention Skills Training (ASIST), which can be used to train staff in public school districts. ASIST is a 14-hour training created by the company LivingWorks that is grounded in research, Whisenhunt says. UWG’s counseling department does ASIST training with practicum students, and Whisenhunt says they report feeling much more confident once they have taken the course, even though they have already learned a good deal about suicide in their program.

One of the main components of ASIST is the “pathway for assisting life,” Whisenhunt explains. “They have a model for how to have a conversation about suicide with someone.” She tells practicum students that this is a model that summarizes everything they already know, but it presents the information in a format that is easy to keep at hand in a crisis. 

The first part of the model is about connecting with suicide, she says. It has two main tasks: exploring indications of suicide risk and then spotting warning signs and naming them. Once warning signs are identified, trainees learn to act directly without beating around the bush, Whisenhunt says.

Whisenhunt and her follow trainers also instruct workshop participants on how to talk about suicide and what to do if someone is expressing suicidal thoughts. She warns participants not to ask, “Are you thinking of hurting yourself?” because that could mean many different things to the person. Instead, she encourages training participants to be direct and not be afraid to use the word “suicide.” For example, they could ask, “Are you thinking of killing yourself? Are you thinking of suicide?”

She also advises them not to ask leading questions. “If you ask, ‘You’re not thinking about suicide, are you?’ the person knows the answer you want them to give,” Whisenhunt explains. “If the person seems hesitant, trust your gut, talk a bit more, make them feel more comfortable, and circle back around.”

She also tells people to keep asking about suicide. Don’t just ask once and feel “relieved that you got that out of the way,” she insists. “If you felt like you needed to ask and the answer doesn’t feel right, ask again,” she says. “A lot of people don’t want to die — they just want the pain to end. Help them know there’s another way out.”

Counselors also need to be prepared to provide resources, Whisenhunt adds. She advises her trainees to keep hotline numbers in their phones and to carry suicide prevention cards in their wallets. 

“When talking with an individual and hearing about their despair, chances are you are going to hear something that means that they don’t want to die. It’s often something like, ‘I don’t want to leave my dog,’” Whisenhunt says. “If you hear that little thing that says they don’t want to die, you don’t [want to] be manipulative, [but] you say, ‘I know that you’re in a lot of a pain, but it seems to me like you’re still thinking about living because you want to be there to take care of your dog.’ That’s the turning point — where they start to turn away from suicide and toward life.”

Counselors can then ask clients if they want to develop a plan to keep them safe for now, Whisenhunt continues. The use of the phrase “for now” is important, she stresses, because when people are in a suicidal crisis, talking about living for years and years is overwhelming to them. The safety plan should be for a matter of hours or days — just until the person can be connected with help, she explains. 

The ASIST safety plan includes “safety guards” and “safety aids.” Whisenhunt says safety guards include protecting clients from risk factors such as a plan to die by suicide, problematic alcohol or drug use, prior suicidal behavior, or mental health concerns that might exacerbate risk. Counselors can help clients consider ways to mitigate these risks such as by reducing or eliminating drug use. 

Guarding also involves being mindful and looking at previous suicide attempts for clues to keep the client safe, Whisenhunt adds. For example, the client might be impulsive, so part of keeping them safe involves having someone stay with them for a few days. 

Safety aids are elements that help improve a person’s chances of staying safe, Whisenhunt explains. Counselors can help clients consider the strengths they already possess and the supports they need to build. “It’s strengths-based,” she says. “We try to help individuals see their strengths and resilience and see options to help them feel better.”

Being prepared 

Counselors may be trained in suicide assessment and prevention, but putting that knowledge to use can still be a scary prospect, Zalewski acknowledges. For that reason, she stresses the importance of specialized training. If possible, she recommends that counselors find a local training opportunity with someone who can continue to serve as a resource for them afterward. She chose to work with a mobile crisis unit to learn more about helping those in suicidal crisis.

“There are a lot of modalities out there for suicide assessment,” Zalewski notes. “I would recommend not just picking one modality to learn. To be competent, you have to have a good understanding of what’s out there. Whatever you choose to work with has to mesh with you as a human. Explore what’s out there [and] learn several. … It’s well worth it, so when you are faced with some child who has decided they don’t really feel like living anymore, you’re not looking in your file cabinet or texting saying, ‘OMG.’”

Supervision is also essential, Zalewski stresses. “As counselors,” she says, “it’s easy to get to the point where you think, ‘I’ve been doing this for years, and I don’t need supervision.’” But that’s not the case. Sometimes, Zalewski says, she’s certain that she knows something, but supervision helps her realize that somewhere along the way, what she thought she knew got twisted. 

Counselors also need to have their own sources of support when doing this difficult work. “If you’re working with children and adolescents who are suicidal, it is a heavy weight,” Zalewski acknowledges. “It is so easy to question yourself.” And if the all too imaginable happens and a client completes suicide, the counselor is going to need backup, she adds. 

“Everyone in the end makes their own decisions,” she says. All that counselors can ultimately control is the level to which they provide clients with the best preventive tools, and “a good supervisor will help you assimilate that.”

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Laurie Meyers is senior writer at Counseling Today. Contact her at LMeyers@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.