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Children & Adolescents

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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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.

 

Coming to grips with childhood adversity

By Oliver J. Morgan September 7, 2017

Counselors and mental health professionals of all stripes are coming to understand the prevalence of childhood adversity, toxic stress and trauma in our caseloads. Barely a day goes by that we do not see someone with a trauma history, whether we are aware of it or not. Some have even called for universal trauma screening of all clients and patients as an ethical responsibility, especially for those individuals who are more at risk, including first responders, military personnel, refugees, those with serious medical and chronic illness, and people struggling with addiction. It would help to know what we are dealing with upfront.

I became aware of a duty to inquire about trauma in 2007 when I began the Supportive Oncology Service (SOS), a psychosocial counseling practice colocated in a medical oncology setting. I had been teaching, practicing and publishing mostly in addiction studies at the time, but I was hungering for change in my own clinical work. When the opportunity to work alongside physicians and learn about serious medical illness came along, I jumped at it. Quickly, I discovered that what I was learning about the interface between addiction and trauma could just as easily be applied to the occurrence of trauma in a cancer-involved population. This cross-fertilization of ideas and their practical outcomes has been a rich source of learning for me.

The Adverse Childhood Experiences (ACE) studies, a collaborative project between Kaiser Permanente and the Centers for Disease Control and Prevention (CDC), instigated my interest. The ACE project was designed to study long-term relationships between adverse experiences in childhood and adult health and behavioral outcomes. I had begun looking into this as an offshoot of my addiction work but promptly came to realize its applications in the general population. The initial studies were conducted from 1995 to 1997 with 17,000 ordinary Americans in a large outpatient medical clinic and now have been replicated across a number of states and even internationally.

Since its inception in 1995, numerous papers have been published by the ACE project that present the evidence for consistently strong and graded relationships between adverse experiences in childhood, household dysfunction and a host of negative health outcomes later in life. Many of the most serious illnesses facing our country — heart disease, cancers, chronic lung and liver disease, a host of autoimmune disorders, obesity, substance-related and addictive disorders — as well as a variety of health-risk behaviors, including smoking, use of illicit drugs, high numbers of sexual partners and suicide attempts, are strongly related in a dose-response or graded fashion to childhood adverse experiences.

This suggests that the impact of adverse childhood experiences on adult health status and adult suffering more generally is powerful. Dose-response relationships indicate a change in outcome (e.g., harmful substance use or ischemic heart disease) that is associated with different levels of exposure to a stressor. Experiencing multiple categories of trauma in childhood increases the prospects for later illness. ACE studies measure the number of categories of exposure and not the number of instances; for example, one instance or multiple instances of sexual assault would count as one category. If anything, this underestimates a person’s exposure to adverse experiences.

Researchers are finding that the occurrence of adverse experiences is quite common in all populations. Relationships found in the original population are being replicated elsewhere. Fifty-two percent of those participating in the original study acknowledged at least one category of adversity in childhood. Eighty-seven percent of those who acknowledged one adverse childhood experience also experienced additional adversities. The study revealed that adverse experiences occur in clusters, with 40 percent of the original sample reporting two or more categories of adversity and 12.5 percent experiencing four or more categories of adversity.

The ACE categories are as follows:

  • Physical abuse
  • Sexual abuse
  • Emotional abuse
  • Physical neglect
  • Emotional neglect
  • Mother is treated violently
  • Loss of a parent for any reason
  • Mental illness in the home, including suicidal behavior or institutionalization
  • Substance abuse in the household
  • Criminal behavior in the household, including incarceration of a household member

‘Mild’ adversities?

What first strikes people when they review the categories above is how different the list seems from what we expect. It challenges our assumptions. Many of us are familiar with the standard understandings of trauma connected to natural or human-made disasters, battlefield experiences, violence or sexual assault. Clearly, these are life-altering events. Although these categories are on any list of traumatic events, so are forms of household dysfunction, neglect, and emotional abuse and humiliation. We are coming to understand that, when dealing specifically with children, a wider range of traumatic experiences can be equally devastating and produce debilitating outcomes years later. Further studies are also uncovering negative outcomes related to more “ordinary” adversities such as accidents, childhood hospitalizations or the loss of a sibling.

The ACE results had suggested that the different categories were essentially equal in their damage. This was startling. However, ongoing trauma science supports this conclusion. Although some categories of adversity stand out because of the social significance and stigma attached to them, we now know that more hidden or subtle adversities, such as neglect and experiences of recurrent humiliation by a parent, can both be detrimental in the present and carry long-term consequences for adult health and psychiatric illness. Scientists such as Martin Teicher and his colleagues at Harvard University have documented the potent negative effects of parental verbal aggression and emotional maltreatment.

More common adversities can have large impacts on children. The clinical and research focus on posttraumatic stress disorder may have slanted our expectations, giving us the impression that adversity comes only with high-profile suffering. If it doesn’t leave a mark, it can’t be all that damaging, right? In reality, nothing could be further from the truth.

In short, poor health and risk for illness — medical as well as psychiatric — can be rooted in childhood psychosocial experiences. They can also be hidden due to time, denial and social taboo. The ongoing ACE studies and allied research have given us a new lens for viewing health, wellness and disease. This is nothing short of revolutionary. It is instructive that this new vision has been picked up by the Center on the Developing Child at Harvard University and the American Academy of Pediatrics. Programs for medical education, intervention and prevention are being developed by these groups and others.

Looking at cancer

In 2010, one of the ACE papers made the dose-response link to risk for lung cancer. This got my attention. Adverse childhood experiences are obviously not the only causes of cancers — disease is often multicausal. However, the associations this paper made between having a history of adverse childhood experiences and those who were first hospitalized at younger ages with lung cancer and died prematurely at younger ages from lung cancer were striking. Smokers were much more likely to have a history of adverse childhood experiences than were nonsmokers. In addition, those with adverse childhood experiences were more likely to begin smoking at younger ages than were other smokers.

I was amazed until I went back and did a chart review for my small oncology service. At that time, we had seen about 100 patients. Admittedly, this was a potentially skewed population, but even so, 60-70 percent of our patients with a variety of cancers met the ACE criteria for adverse experiences, and a large proportion of them had multiple ACE categories in their past. Research had suggested that those with four or more categories of childhood adversity were likely to be diagnosed with cancer or some other serious illness. Those with six or more categories had a life expectancy shortened by up to 20 years. My patient population buttressed those numbers. In addition, several of my patients who were not smokers but nevertheless were diagnosed with lung cancer did have a history of trauma. That day I became a believer in universal screening for trauma in my population of cancer patients. My colleagues and interns have also become believers.

When I discussed these outcomes with several of my physician colleagues, they quickly came to the conclusion that because childhood adversity was strongly associated with the risk of early smoking — nicotine is a powerful anti-anxiety agent — that would likely explain the prevalence among patients with lung cancer. Case closed. If a cancer patient also had a traumatic childhood history, smoking was the likely pathway from trauma to lung cancer. Risky behavior led to later disease.

This did not sit well with me, however. First, it did not explain the high trauma numbers in my cancer patients more generally (a number of whom were nonsmokers) and, second, identifying only this pathway seemed too facile. I believed that more was involved.

Changes that make us vulnerable

At first blush, ascribing disease to risky behaviors and poor lifestyle choices seems reasonable. There is obviously some truth to it. Lots of scientific evidence points to smoking as a risk for cancer. Still, I wondered, could there be other pathways from childhood adversities to cancer? The connections seemed clear, but what were the explanations? As an addiction specialist, I was suspicious of the “poor choices” explanation. Were there other, hidden dynamics that were not so obvious?

This is where the intersection of childhood adversity and neurobiology becomes so important. As a counselor, I had focused my thinking on the social and psychological explanations. Childhood adversity short-circuited psychosocial development. Trauma created toxic stress in a person’s life. Negative experiences became part of a person’s sense of self and view of the world, which made living difficult. These negative experiences also placed emotional burdens on the person’s psyche and spirit, creating negative internal images, expectations and attachments at the core of the personality. People learned to be wary of others and became more guarded, isolated and distrustful. Fair enough. But how do we get to physical disease?

This move requires an alchemical kind of insight — namely that the footprints of our psychosocial experiences of attachment and caregiving are inscribed into our brains and bodies in what Allan N. Schore, Daniel J. Siegel and others call “psychobiological” experiences. Donna Jackson Nakazawa, in her 2015 book Childhood Disrupted, described it this way: Biography becomes biology.

We are continuing to learn about the depths of this process. From our earliest beginnings, experience shapes the development of our brains, bodies and critical survival systems. The formation of our neural architecture, emotional and cognitive networks, regulatory systems, coping and stress response, and immune systems depends on the kinds of caretaking we receive. Social networking is part of our DNA it seems; it is essential for our survival but can also create vulnerabilities.

In childhood, all the essential systems are forming and developing. When children are caught in cycles of abuse, neglect or humiliation, their stress response and coping mechanisms can be degraded and become stuck in the “on” position. Their bodies are continually bathed in inflammatory stress chemicals. This can lead to physiological changes, long-lasting inflammation, eventual breakdown and disease. The immune system can be weakened, even at the level of genes. Neuroscience is helping to document these enduring kinds of changes, large and small, that are the pathways to later illness.

Another form of negative development that can follow from childhood adversity affects the child’s regulatory coping mechanisms for stress. This can lead to difficulties such as substance use and addictive disorders. Emotional and behavioral regulation are essential skills, built upon the foundation of neurological development. Toxic stress, however, can alter and “miswire” the development of critical coping systems, resetting their baseline levels of activity and making them supersensitized, not only to stress but also to triggers that signal the approach of rewarding or stressful situations. In these instances, individuals may substitute chemical or behavioral forms of coping, reward, relieving stress or alleviating anxiety and pain. Regularly resorting to such substitutes can ingrain these choices into neural channels that are resistant to change once firmly set.

These ways of thinking have opened my eyes. Childhood maltreatment and adversity alter children’s brain development and create the underlying conditions for short-term coping and long-term medical and psychiatric problems, including cancers and addiction. The intersection of knowledge from developmental psychology, attachment theory, trauma and neuroscience is presenting us with many new ways to conceptualize the challenges that confront us. As counselors, it is imperative that we remain open to these new developments.

Recommendations

Based on my experience, I want to make some practical recommendations:

1) Counselors need to learn all we can about adverse childhood experiences and their impact on adult living.

2) We can all benefit from universal screening for adversity and trauma as a first step in clinical work. A few simple questions can be added to our standard history taking. Asking these questions on an abstract or computerized form, followed up with face-to-face conversation, has been found to be the best practice for obtaining accurate information. There may be direct health benefits to these conversations. As reported in Nakazawa’s book Childhood Disrupted, physicians who discussed adverse childhood experience questions with patients following completion of intake forms found a 35 percent reduction in office visits and an 11 percent reduction in emergency room visits for patients with chronic ailments over the ensuing year.

3) When we discover a history of adversity, we should remain curious, be empathic and be predisposed to believe. The primary consideration initially is creating a safe space.

4) Be prepared for pendulum swings in the conversations. It is normal to move forward in the story and then back off when the client shows anxiety.

5) Teach grounding techniques so that the client can retreat to safety when overwhelmed.

6) As is the case in much of our counseling work, self-knowledge is critical. Each of us can benefit from conducting our own self-assessment of adversity and trauma. Understanding our own issues and working with them may be the most important first step in recognizing the problem and then working with others.

Good luck. This work, I believe, is one of the greatest secrets and potential resources in clinical practice today. Trauma continues to be a hidden occurrence among our clients and patients for too many counselors, physicians and human service providers. We need to do better.

 

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Oliver J. Morgan is a professor of counseling and human services at the University of Scranton in Pennsylvania. He is beginning his 27th year at the university and is completing a book titled Hungry Hearts: Unlocking the Secrets of Addiction and Recovery. Contact him at oliver.morgan@scranton.edu.

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

 

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

’13 Reasons Why’: Strengths, challenges and recommendations

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

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

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

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

 

Strengths

1) Raising awareness that suicide is a real problem.

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

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

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

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

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

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

3) Suicide is complex and individual.

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

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

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

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

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

4) The central message is a positive one.

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

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

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

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

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

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

 

Challenges

1) Graphic nature and contagion

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

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

2) Survivor’s guilt and revenge fantasies

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

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

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

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

 

Recommendations

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

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

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

2) We need more than prevention programming in schools.

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

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

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

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

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

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

4) Use an intervention model backed by research.

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

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

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

 

Summary

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

 

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

 

 

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

 

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

 

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

 

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

FASD: A guide for mental health professionals

By Jerrod Brown July 10, 2017

Fetal alcohol spectrum disorders (FASD), which researchers have estimated affect 2 to 5 percent of the U.S. population, are lifelong conditions that result from exposure to alcohol in utero. Kenneth L. Jones, David W. Smith and colleagues are credited with discovering the birth defects and long-term impacts on cognitive and social functioning caused by fetal alcohol syndrome in 1973.

Prenatal alcohol exposure can result in a host of issues related to:

  • Cognitive functioning (e.g., impulse control, attention, executive functioning)
  • Social functioning (e.g., communication skills, recognition of social cues)
  • Adaptive functioning (e.g., problem-solving, ability to adapt to new situations)

Furthermore, several neurological issues characterize FASD, including stunted cell and nerve growth, elevated rates of cell mortality, neurotransmitter interruptions and migration issues in organic brain growth. Complicating matters, the overwhelming majority of individuals with FASD experience an array of psychiatric disorders, increasing the likelihood that these individuals will need specialized services from mental health care providers.

Unfortunately, many of these providers and professionals lack the necessary training and expertise to accurately identify and effectively treat the unique and complex symptomatology of this population. The goal of this article is to provide a basic introduction of FASD to mental health professionals in six key areas: FASD symptoms, diagnostic comorbidity, memory impairments, tips for interacting with individuals who may have FASD, screening and assessment, and treatment.

FASD symptoms

A diverse range of symptoms characterizes FASD.

Executive functioning deficits: Impairments associated with executive functioning are a hallmark deficit of FASD, impacting the majority of individuals affected by these disorders. Executive functioning deficits are often associated with impulsivity, diminished ability to learn from consequences and impairments in planning, verbal reasoning, emotional regulation, memory and learning.

Social skills deficits: Individuals with FASD often have pervasive impairments in the domain of social functioning. Misinterpretation of social cues is not uncommon. This can lead to boundary violation concerns (e.g., inappropriately touching another person), which can in turn result in involvement in the criminal justice system. Such social skill deficits can also increase the individual’s level of vulnerability to manipulation by others and an inability to detect unsafe situations and people.

Attachment problems: Consistent with these deficits in social skills, poor attachment with the primary caregiver is relatively common in children with FASD. Poor attachment with the primary caregiver can increase the likelihood of misdiagnosis in a child. Common misdiagnoses may include attention-based (e.g., attention-deficit/hyperactivity disorder [ADHD]) or behavior-based disorders (e.g., conduct and oppositional defiant disorders). In fact, it is not uncommon for these disorders to co-occur with a diagnosis of FASD. Given that reality, mental health professionals who work with individuals impacted by FASD should familiarize themselves with commonly co-occurring disorders such as those just mentioned.

Adaptive functioning: Adaptive functioning involves an individual’s practical, social and mental capacities to deal with everyday challenges and problems (e.g., personal hygiene, personal finances, navigating social interactions). In light of the executive functioning problems outlined earlier, as well as struggles with processing abstract information and solving problems, individuals with FASD have difficulty in the realm of adaptive functioning. The consequences can range from difficulty maintaining employment to struggles with caring for one’s self. Because of these deficits in adaptive functioning, a high percentage of individuals with FASD are dependent on the support of family and social services.

Learning problems: One of the key issues related to adaptive functioning among individuals with FASD is difficulty learning from past experiences. Furthermore, individuals with FASD often struggle to use past experience to prospectively avoid dangerous people and situations. These deficits are exacerbated by impulsivity and an inability to think strategically about decisions. Hence, FASD affects an individual’s ability to understand society’s norms and to behave within those norms.

Diagnostic comorbidity

Increasing the likelihood of negative short- and long-term outcomes, individuals with FASD often have co-occurring disorders and other issues.

Diagnostic comorbidity: It has been estimated that the overwhelming majority of individuals with FASD experience comorbid psychiatric conditions. ADHD is the most prevalent comorbid disorder observed among those affected by FASD. Other disorders frequently observed among adolescents with FASD include conduct disorder and oppositional defiant disorder. Finally, individuals with FASD are also at an elevated risk to abuse substances later in life.

Physical complications: A number of physiological symptoms can suggest the possibility of FASD. For example, prenatal alcohol exposure can result in cardiovascular (e.g., septal defects, hypoplastic pulmonary arteries) and kidney (e.g., pyelonephritis, hydronephrosis, hypoplasia) irregularities. Prenatal alcohol exposure has also been linked to orthopedic irregularities in the structure of bones in the upper body (e.g., radioulnar synostosis), fingers and toes (e.g., camptodactyly, brachydactyly, clinodactyly).

Other brain-based injuries: Individuals with FASD may be more prone to traumatic brain injuries throughout the life span. This could contribute to the underdiagnosis and misdiagnosis of FASD. Furthermore, these traumatic brain injuries may exacerbate other secondary conditions, including ADHD, executive functioning impairments, mental health and substance use disorders, and so on.

Other life adversities: As a function of FASD and these other co-occurring disorders and impairments, individuals with FASD are disproportionately likely to be afflicted with problematic life experiences. For example, individuals with FASD often come from unstable homes, experience neglect and abuse (verbal, physical or sexual), and are exposed to substance use, mental illness and criminal justice involvement by their families and household members. As such, mental health professionals should view these co-occurring disorders and other negative life experiences as potential indicators of FASD, necessitating a need for further assessment and evaluation.

Memory

One of the most devastating cognitive deficits of FASD is short- and long-term memory impairment.

Poor memory: Individuals with FASD typically have problems associated with memory. In some instances, these issues can lead to over- and underendorsement of symptoms, contributing to missed and misdiagnosis. In other instances, these individuals can struggle with retrieving and communicating their memories, contributing to issues such as suggestibility, confabulation, fabricating stories and incorrect storytelling.

Suggestibility: The suggestibility of individuals with FASD can be detrimental in at least two ways. First, these individuals may be manipulated into participating in criminal activity by peers. Second, these individuals may be prone to falsely confessing to criminal activities that they did not commit. As such, mental health professionals must take care to verify the accuracy of statements made by individuals with FASD. Mental health professionals should also take the topic of suggestibility into account when phrasing and asking questions during the initial intake and diagnostic assessment process.

Confabulation: FASD and other disorders characterized by memory deficits often co-occur with confabulation issues. Confabulation occurs when new memories are created by filling gaps in recall with one’s real memories, imagination or environmental cues. Incidents of confabulation may occur spontaneously or be prompted. For example, confabulation is particularly likely in situations in which professionals ask leading questions or pressure the interviewee. As such, confabulation can contribute to inaccurate self-reports by the client, resulting in possible misdiagnosis and the development of an ineffective treatment plan.

Interacting with clients

The pervasive symptoms of FASD have important implications for how mental health professionals should interact with clients who may have these disorders.

Importance of simplicity: Individuals with FASD tend to perform better when tackling one task at a time. This is especially true of tasks that do not involve reliance on previous experience to complete. Multistep and complex questioning can result in individuals with FASD shutting down emotionally or responding with factually incorrect or incomplete responses. Mental health professionals should take this into account when screening, assessing and developing treatment plans for this population.

Superficial talkativeness: The propensity for individuals diagnosed with FASD to be charming and talkative may lead mental health professionals to overestimate their level of competence and comprehension of treatment goals. It is important for clinicians to have these individuals demonstrate understanding and knowledge of the question being asked by explaining it back to the professional in their own words. Overuse of yes-or-no questioning can also mask the individual’s true level of impairment.

Misinterpretation of callousness: In some cases, behaviors resulting from FASD symptoms might be mistaken as a choice rather than as a result of the disorders. The social and cognitive deficits of individuals with FASD can contribute to problematic behaviors being misinterpreted as premeditated or manipulative. In fact, many of the behaviors exhibited by individuals with FASD are the direct result of deficits caused by prenatal alcohol exposure.

Screening and assessment

The combination of nuanced symptomatology and diagnostic comorbidity makes the screening and diagnosis process for FASD difficult.

Diagnostic terminology: FASD is an all-encompassing term that includes fetal alcohol syndrome, partial fetal alcohol syndrome, alcohol-related neurodevelopmental disorder and alcohol-related birth defects. In the fifth edition of the Diagnostic and Statistical Manual of Mental Health Disorders (DSM), neurodevelopmental disorder-associated with prenatal alcohol exposure has been added as a condition for further study. This is the first appearance of FASD-related symptoms in the DSM, which means mental health professionals can now diagnose prenatal alcohol exposure.

Missed and misdiagnosis: Missed and misdiagnoses of FASD may explain, at least in part, the limited awareness of the disorders among medical and mental health professionals. A lack of systematic education and training on FASD contributes to this situation. As a result, many children, youth and adults go unidentified and are subsequently unable to take advantage of advanced medical and psychological treatment and services that could render a better quality of life.

Detection difficulties: Another factor that likely contributes to the missed and misdiagnoses of FASD is the fact that these disorders are difficult to identify. Why is that? Visible indicators such as morphological signs are not always present, whereas cognitive deficits are difficult to detect using standardized intelligence measures. This is problematic because individuals with FASD who present with no outward signs of facial feature abnormalities can still possess severe neurobehavioral deficits. In fact, diagnosis of prenatal alcohol exposure becomes increasingly difficult as children grow into adolescence and adulthood. Specifically, many of the physical features of prenatal alcohol exposure fade as children grow physically. Furthermore, the availability of birth mothers and records decrease with time. As a result, many professionals and researchers have called FASD a “hidden disability.”

Importance of identification: Assessment and identification of FASD are essential because the likelihood of impairment related to alcohol exposure increases significantly with each subsequent pregnancy. Identification of these disorders in a first pregnancy provides a viable point of intervention to help prevent alcohol use in future pregnancies.

Treatment

Even in cases in which the individual has been accurately diagnosed with FASD, treatment can be challenging.

Problems with cognitive-based treatments: Individuals with FASD have cognitive (e.g., memory, understanding cause-and-effect), social (e.g., comprehending social cues) and adaptive (e.g., problem-solving ability, generalizing skills) deficits that complicate their participation in cognitive-based treatment. Likewise, insight-based therapy approaches are not encouraged with this population. Therapeutic approaches that incorporate modeling, coaching, teaching and skill building may be most effective with these individuals.

Problems with treatment adherence: Individuals with FASD may benefit more from treatment in structured residential facilities than in outpatient facilities because of the cognitive deficits associated with FASD. Should an outpatient program be the only option, odds of treatment success may be improved by maximizing program structure and tailoring treatment plans to the individual.

Conclusion

The disorders under the FASD umbrella are complex and lifelong. They are characterized by an array of adaptive, behavioral, emotional, executive, physical and social impairments. Considering the prevalence rates of FASD in the United States, it is highly likely that mental health professionals will come into frequent contact with individuals impacted by these disorders. Unfortunately, these disorders often go unrecognized and undiagnosed by many mental health professionals.

Other than simply improving identification of individuals with FASD, another essential step for mental health professionals is to better understand the various challenges and deficits faced by this population on a daily basis. To combat the status quo, mental health professionals are encouraged to seek training on this complex topic and consult with FASD experts when necessary. Taking this path forward will minimize the likelihood of negative short- and long-term outcomes for this population.

 

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Jerrod Brown is the treatment director for Pathways Counseling Center Inc., which provides programs and services benefiting individuals affected by mental illness and addictions. He is also the founder and CEO of the American Institute for the Advancement of Forensic Studies and the editor-in-chief of Forensic Scholars Today. He holds graduate certificates in autism spectrum disorder, other health disabilities and traumatic brain injuries, and is certified as a fetal alcohol spectrum disorders trainer. Contact him at Jerrod01234Brown@live.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.

Through the child welfare kaleidoscope

By Sheri Pickover and Heather Brown June 27, 2017

The amazing feature about kaleidoscopes is the endless, ever-changing scenes and complex patterns they reveal to anyone who takes the time to look. The gentlest of rotations invites a new and oftentimes completely different perspective on the same set of colorful shapes.

Working with children, adults and families involved in the child welfare system is not so different. A vast array of interplaying events, reactions, concerns and characteristics make up a mosaic of factors that drive a counselor’s assessments and interventions. Any counselor who has worked with one or 100 cases involved in foster care understands how complex and overwhelming it can be to help this population. However, in using the metaphor of looking through a kaleidoscope, we are reminded of how one gentle turn of our focus can change our perspective of the case at hand in a way that will continuously drive more attuned, meaningful interventions. Knowing that the myriad shapes exist before, during and after our treatment with these clients, we can more easily remain open both to seeing and making sense of our clients, the child welfare system and its players, as well as our own experiences of these cases.

Given that each turn of the kaleidoscope brings a new feature into view, we have some idea of the shapes that are there: neglect or abuse, histories of mental illness and substance abuse, court involvement, grief and loss, trauma and attachment. One element might stand out from the others at different times during treatment, but all are present in the kaleidoscope, and we should always acknowledge them throughout the course of treatment even when they don’t dominate our view.

In this article, which is based on our book Therapeutic Interventions for Families and Children in the Child Welfare System, we will provide an overview of six perspectives, or “turns of the kaleidoscope,” to take with these cases. These perspectives focus on specific considerations and guided structure to drive effective intervention and counter burnout when working with this population.

First turn of the kaleidoscope: Client worldview

When a client is involved in the child welfare system, instead of beginning treatment with assessment, start with a curiosity about the client’s worldview (whether that client is a child or an adult) and a desire to understand that worldview better. This process builds empathy for the client and reminds counselors to evaluate possible motivations for the presenting behavior concerns. What is it like to be a child in foster care? What is it like to have your child removed from your care? What it is like to care for a child you don’t know in your home?

Many factors influence the worldviews of children in foster care:

  • Exposure to traumatic events such as being removed from their homes and the abuse or neglect that prompted removal
  • Shame and guilt related to blaming themselves for the removal
  • Their attachment style with their family members
  • Grief from multiple losses (home, school, friends, neighborhood)
  • A sense of constant chaos and a fear of what will happen next that is beyond their control

Children in foster care wonder if they will ever be safe, and if a child has experienced frequent foster home place disruptions, this fear only intensifies.

Birthparents’ worldviews begin with the helplessness and hopelessness that humans feel at losing their children. Grief and loss are compounded by judgment from family, friends, court personnel, therapists and case managers. The reason for removal, such as ongoing substance abuse, their own history of trauma or attachment issues, possible mental illness, poverty or a lack of educational opportunities, is further complicated when their family enters the child welfare system. Often viewed as resistant or unwilling to accept responsibility for their actions, these birthparents often feel alone and angry and use their energy to defend themselves against the onslaught of judgment.

Ironically, foster parents’ worldviews may also begin with helplessness. Although they receive training and support, sometimes it is not enough to counteract the effects of caring for a child in their home who is angry, traumatized, grieving and filled with anxiety. In fact, the experience of foster parents can be similar to that of the child’s birthparents in that they are quickly judged and required to abdicate control in their home to the child welfare rules and a series of child welfare workers. Foster parents are also asked to love a child and then let that child go, so they struggle with attachment, grief and loss issues on a constant basis.

Second turn: Counselor worldview

As counselors, what we see in others is often influenced by our own family histories, personal values and clinical experiences. These issues rise up early in the child welfare system, where counselors are often novice professionals just starting out, and they are given clients with chronic treatment issues who have often seen myriad other professionals.

Meanwhile, the pressure from the systems and individuals involved is often overwhelming. Counselors often feel responsible to “fix the kid” or “fix the family,” and this pressure can lead to countertransference, ethical violations and burnout. These children and families often exist in chaos, and counselors can easily be pulled into that chaos by a system that expects miracles but provides minimal support. The child welfare kaleidoscope can become a series of fast-approaching shapes, constantly spinning with what appears to be little direction, or it can become stuck, making it difficult to move or view another shape.

Counselors must always be on guard against the creeping sense of helplessness and the compassion fatigue that can occur when working with this population. Counselors must also combat the countertransference that can force the kaleidoscope to become stuck on one shape or color. Seeking qualified supervision with professionals who are experienced with this population can make a world of difference. Making self-care practices a necessity rather than a commodity will help protect counselors against compassion fatigue.

When working with this population, counselors can be pulled toward feeling pity or overwhelming sympathy for these clients. On the other side of the coin, they can find themselves judging or feeling angry with these clients, either for how the adults behave toward their children or how the children seem ungrateful toward the adults. These are all ineffective responses, both for the counselors and for their clients.

Using the metaphor of a bridge, remember that to stand in empathy is to stand on the rickety, scary bridge over raging waters to allow ourselves to feel what our clients feel. Either side of the bridge — pity or judgment — feels “safer,” but they both lead to ineffective therapy and further harm to the client. Closely evaluating your own personal values before beginning this work and knowing the child welfare laws in your state will provide necessary support to curate an empathic, realistic perspective on your cases.

Working with children in foster care also can be a minefield of ethical issues. Confidentiality can be complicated depending on the referral source and the child’s legal status. For example, the birthparent of a temporary ward of the court still possesses legal rights and must be consulted over treatment issues. At the same time, the child is placed in foster care, and foster parents need to be made aware of important issues that might impact the child in their home. The court might subpoena therapy files, and caseworkers also require treatment updates and recommendations. Each of these possible breaches is relevant to informed consent with this population.

The issue of mandated reporting can also become a prominent part of treatment. Children may disclose abuse in the birth home, foster home or both. Managing the ongoing relationships with birthparents and foster parents when required to report suspected abuse or neglect requires counselors to be honest, forthright and empathetic at all times.

Finally, facing clients with complicated trauma, grief and attachment histories can become demoralizing for counselors because they rarely see the type of progress that allows for professional satisfaction. The potential for experiencing vicarious or secondary trauma responses is also high. Counselors working with this population should engage emotional support from peers, supervisors and even their own counseling. These actions can help heal emotional wounds, keep the work in perspective and prevent the type of burnout that ends up hurting rather than helping clients and counselors alike.

Third turn: Assessment

Assessments with clients involved in child welfare must be understood as living documents of sorts. After all, anything captured at one particular time can be expected to shift because of the unstable nature of so much that influences the client’s life in profound ways. Counselors should obtain ongoing strategic updates on the child’s behavior, emotional status and the status of the relationship with the birthparent, then adjust goals accordingly. For example, try to find out when a placement transition or court-ordered change in permanency status takes place, when the client experiences an additional loss or traumatic exposure, or when the client newly acknowledges a past traumatic exposure.

Counter to the tendency of many counselors to see the concerns of each case first, this population greatly benefits from intentionally identifying their strengths during the assessment process. Children and adults who are involved in the child welfare system often possess amazing resilience, creative coping skills, abundant humor, deep love and extraordinary courage.

Beyond just accounting for strengths, effective assessment looks around the kaleidoscope, gaining information on all aspects of clients’ lives, not just the current presenting problem. Clients in the child welfare system often get viewed through one shape in the kaleidoscope — their behavior. As a result, trauma, grief and attachment concerns often get lost in the desire to stop the current behavior and the pressure felt to “fix the child” or “fix the parent.”

Assessment of the child begins by listening and watching: listening to a child’s stories, listening to the reports of both the foster parents and the birthparents, and watching how the child plays and interacts with you, other siblings and adults. Attachment style will be evident by whether the child seems angry or withdrawn from adults, or whether the child clings and appears fearful. The child’s response to trauma will be evident through sleeping patterns, the way the child eats and the level of fearfulness the child exhibits at home and at school. Educational information and potential medical concerns also may be highly relevant to interventions.

In addition, the amount and type of losses the child has endured and the child’s grieving process matter greatly. Taking session time to normalize the child’s reaction to removal from the home and any subsequent placements can have a significant impact on the child’s adjustment efforts. Finally, after examining and prioritizing behavior problems and building an understanding of what is driving them, work with the families to create a realistic and achievable plan that focuses on one or two concerns at a time. Using this approach, the counselor can keep the many parts of the client’s kaleidoscope in mind while knowing that trying to work on everything at once would be ineffective.

One common challenge in working with this population is the tendency to turn therapy into nonstop crisis intervention sessions, responding to the complaints of foster parents or case managers rather than holding steady to the set treatment plan. Although crisis management is necessary at times, learn to determine what is truly a crisis (e.g., suicidal ideations, homicidal ideations, an immediate risk of removal) and what qualifies as an ongoing complaint (e.g., trouble in school, acting out in the foster home). Holding focus on just two or three shapes at a time prevents therapy from turning into a nonstop process of confronting the child.

Fourth turn: Treatment

Beginning treatment for any primary concerns with this population must focus on giving the child and family space to feel safe and comfortable. For example, get on the child’s eye level, allow the child to move freely throughout the room, and be clear and open about what therapy is and is not. Because treatment is often specific to the needs of the child, be sure to research and seek training in specific interventions related to trauma, attachment, grief and loss, or behavior issues. The following brief case studies illustrate an intervention for each treatment issue listed above.

Trauma: A 15-year-old girl came into care for the second time in her life because of allegations of sexual abuse by multiple family members. She barely was eating or sleeping and kept her body and hair covered with multiple layers of clothing at all times. The counselor took time to connect with her in simple ways that she could handle — drawing, listening to a song she liked, smelling a favorite hand lotion, updating her on the status of her many siblings and naming how much had changed since she had come into care and how normal it would be to feel overwhelmed. Creating this routine of predictable, soothing interactions built a sense of psychological safety in the therapy space. From there, the counselor helped her learn how to lower her arousal enough to open up about her inner world. This allowed her to begin the long and life-changing intensive trauma treatment process that had previously been inaccessible to her.

Attachment: The counselor used a metal Slinky as a transitional object with a 7-year-old boy who refused to enter the counseling room. The counselor brought out the Slinky, and the boy played with it as he ran around the waiting room, not responding to verbal prompts or directions. When he stopped, he and the counselor would go and walk the Slinky up and down the stairs. After three sessions, the counselor stated that to play with the Slinky, the boy had to enter the counseling room. He was able to enter for a short time in the first week and stayed for the entire session from that point forward.

Grief and loss: An 11-year-old girl had witnessed her mother die of breast cancer in her home. The child had limited verbal skills and would draw pictures of herself jumping rope with her mother in the sky. Using her art, the counselor encouraged her to draw herself as she currently felt. She drew herself crying with her mother in the sky. As treatment progressed, she could draw herself smiling as she jumped rope, and this action was identified as showing her mother that she was coping. The counselor arranged to have the pictures sent to her mother in a balloon so that her mother could see she was starting to cope.

Behavior modification: A 10-year-old boy acted out constantly and did not respond to normal punishment. The counselor created a “caught being good” plan. The child received a star for every positive behavior and a check for every unwanted behavior. To earn his reinforcing reward — an allowance — he had to be good only one more time than he was bad. The counselor encouraged the foster parent to set the child up to win the reward, so he gained stars for stopping in the middle of acting out or for flushing the toilet. He received lots of verbal praise for the stars and no verbal response for the checks.

Fifth turn: Engaging adults

Perhaps the greatest challenge for counselors working with children in foster care is finding a way to also work with the myriad adults involved in the system. These adults include birthparents and any involved relatives, foster parents, caseworkers, casework supervisors, attorneys, educators and medical professionals, to name a few.

It’s easy to become stuck in silo thinking, focusing only on the therapeutic process in your sessions and becoming frustrated when others do not support or engage in the treatment. During this turn of the kaleidoscope, counselors can remember to picture the colors and shapes of all the other involved adults, including these adults’ own histories of trauma and their own feelings of helplessness and frustration. This will help counselors keep empathy at the forefront of all interactions, thereby avoiding blame and patterns of disempowering, ineffective interactions.

Reframe engagement as something the counselor is responsible for rather than it being the responsibility of the other adults in the child’s life. In other words, counselors need to take on the mindset that it’s our job to work with them, not their job to work with us. That way, if they don’t engage or respond to our efforts, it becomes our responsibility to try different engagement interventions. Trying different approaches might engage an adult who otherwise would not work with the counselor.

For example, focus on asking birthparents and foster parents for help with treatment. Identify the birthparent as the expert on her or his child. Even if you do not use the advice or data the parent gives you, the act of asking is often enough to engage the parent.

Another engagement technique involves remembering to praise something about the child and attribute the behavior to the parent. For example, “Your child has such good manners. It’s clear you spent time teaching him.”

Finally, remember to validate foster parents and birthparents whenever possible: “I wonder if you feel judged and belittled by having all these other adults tell you how to raise your child” or “People expect you to just deal with serious problems and don’t listen to your expertise.”

If collaboration with other professionals proves difficult, remember to empathize with their frustration over the many cases they have and the stress of their workload. Attempt to find compromises, such as shifting your schedule or using encrypted email to keep information flowing. Collaboration helps children in foster care in many ways. For example, it keeps these children from having to repeat stories over and over again. It also guards against having their needs fall through the cracks because everyone assumes that someone else is getting a task accomplished. Collaboration also sends a message to these children that they matter and that the adults in charge of their lives are making decisions together.

Final turn: Self-care

We already touched on this topic under the “counselor’s worldview,” but it bears repeating. Self-care cannot be viewed as a luxury when working with this population. It is a necessary set of supports and adaptive coping skills. Self-care is subjective, not prescriptive, so it should involve whatever works for the counselor.

At bare minimum, counselors should seek peer and professional supervision with others who have experience working within child welfare so that counselors can both vent and get validated. Remember that by nature, these cases are heavy with deep psychological wounding that will bring out countertransference one way or another. Building awareness and tending to your own reactions rather than trying to fight or minimize them will only make you a better counselor and person.

Professional development support, training and consultation around specific troubling cases or treatment concerns, such as sexual abuse reenactment, severe posttraumatic stress disorder or deep attachment insecurities, can make a significant difference in supporting feelings of competency and utilizing best practices for the challenges these cases will present. Give yourself permission to notice any signs of depression, anxiety, grief and secondary or vicarious trauma in yourself, and then seek professional support.

It’s also important and helpful to remember that working with clients with complicated trauma and attachment histories can become disheartening because the counselor rarely sees the type of progress that allows for professional satisfaction. Find ways to keep the work in perspective and balance work-life demands. Take time to seek joy and pleasure in life to prevent the type of burnout that ends up hurting rather than helping clients.

 

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

Sheri Pickover, a licensed professional counselor, is an associate professor and director of the counseling clinic in the University of Detroit Mercy’s counseling program. She has been a counselor educator for 13 years and worked in the child welfare system for 20 years as a therapist, case manager, foster home licenser and clinical supervisor. She currently teaches courses in trauma, human development, assessment and practicum. Contact her at pickovsa@udmercy.edu or childwelfaretherapy.net.

Heather Brown is a licensed professional counselor and art therapist in private practice in Detroit. She has more than 15 years of experience working with youth (both in and adopted out of the child welfare system), parents and professionals as a program developer, therapist, trainer and supervisor. Contact her at BrownCounselingLLC@gmail.com or BrownCounseling.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.