Tag Archives: trauma

Informed by trauma

By Laurie Meyers September 22, 2017

In 1995, the Centers for Disease Control and Prevention and Kaiser Permanente began what would become a landmark study on the health effects of adverse childhood experiences. Over the course of two years, researchers collected detailed medical information from 17,000 patients at Kaiser’s Health Appraisal Clinic in San Diego. In addition to personal and family medical history, participants were asked about childhood experiences of abuse, neglect and family dysfunction, such as emotional and physical neglect, sexual and physical abuse, exposure to violence in the household and household members who had substance abuse problems or had been in prison.

Researchers found that the presence of these negative experiences in childhood was predictive of lifelong problems with health and well-being. The more negative experiences a participant had, the more likely — and numerous — these problems became. Another disquieting finding was that adverse childhood experiences were incredibly common. Almost two-thirds of participants had endured at least one adverse childhood experience, and more than 1 in 5 respondents had endured three or more such experiences.

In the decades that followed, this discovery of the prevalence and devastating effects of trauma spurred the development of practices such as trauma-informed counseling, which stresses the importance of recognizing and treating trauma and, most importantly, preventing additional trauma.

Drawing on basic counseling skills

According to the U.S. Substance Abuse and Mental Health Services Administration, programs, organizations or systems that are trauma informed:

  • Realize the widespread impact of trauma and understand potential paths for recovery
  • Recognize the signs and symptoms of trauma in clients, families, staff members and others involved with the system
  • Respond by fully integrating knowledge about trauma into policies, procedures and practices
  • Seek to actively resist retraumatization

In many ways, trauma-informed care involves using skills that every counselor should already possess. “Remain empathic, open, nonjudgmental and steady. Steadiness is particularly important,” says American Counseling Association member Cynthia Miller, a licensed professional counselor (LPC) in Charlottesville, Virginia, whose practice specializes in trauma. “You don’t want to overreact to things a client tells you. But you don’t want to underreact either. Screen for trauma at intake. Don’t just ask a client if they’ve ever been abused or neglected. Many clients won’t define themselves as victims of abuse or neglect, and if you ask it that way, you’ll miss it. Ask behaviorally instead.”

Miller suggests using questions such as, “Has anyone ever hit, punched, slapped or kicked you? Has anyone ever put you down, called you names or made you feel worthless? Has anyone ever touched you without your permission? Have you ever witnessed a violent or upsetting event that really troubled you?”

“If a client responds with a ‘yes’ to any of those questions, ask them if they’d like to share more about it now,” Miller continues. “Help them feel in control of what they disclose and when and how much. Don’t make the mistake of thinking you need all the details and then push to get them. You can retraumatize someone that way. Instead, ask them how they think the experience impacted them and if they think it is related in any way to their current struggles.

“At the opposite end, if they respond to everything with ‘no,’ don’t assume a trauma never happened. It may very well be that they’re just not telling you about it right now because they don’t yet feel comfortable. Stay open to the possibility and rescreen as appropriate.”

When specific questions about trauma don’t elicit answers, ACA member Rebecca Pender Baum, a licensed professional clinical counselor in Kentucky who has worked with survivors of sexual assault and interpersonal violence, often asks clients if there is anything they haven’t already told her that they think she needs to know. She has found that this approach often helps clients express concerns that they have been holding back.

Jane Webber, an ACA member and LPC in New Jersey who has written extensively about trauma and disaster, often mixes less threatening questions in with questions related to trauma. For example, in the midst of gathering basic background on family history, she will ask clients about events such as accidents or a history of falling. She then works up to questions about physical and sexual abuse. Webber emphasizes the importance of counselors using the same calm, steady tone of voice for all questions to prevent distressing the client.

Webber also finds it useful to tell her clients, particularly those on the younger end of the spectrum, that they can answer her questions via text during the session. She says that sometimes clients are more open to texting about things that they might struggle to express verbally.

Webber urges counselors to be intuitive with clients and look for signs of unexpressed trauma such as sweaty palms, restless movement in sessions and failure to make eye contact.

Miller says that she stays alert “for what I think of as disordered self-soothing,” which may include “substance use, self-injury or aggression. Individually, any one of them can be a clinical indicator. As a triad, they’re almost certainly covering up an untreated trauma.”

A different focus

At first, it may seem strange to treat every client as if he or she is a trauma survivor. However, clinicians who use trauma-informed counseling say that the practice is also about changing the overall focus of counseling by moving away from the “problem” approach. That approach demands, “What’s wrong with you? What did you do wrong? What’s making you act that way?” says Webber, a lecturer in the counselor education department at Kean University’s East Campus in Hillside, New Jersey. “[Trauma-informed counseling] is a paradigm shift from what is wrong with the client to what happened to the client.”

Julaine Field, an ACA member and LPC from Colorado Springs who works with traumatized children, agrees with Webber. Field explains that rather than focusing on changing a client’s thoughts or behaviors, trauma-informed care seeks to understand how people react and adapt to experiences.

A trauma-informed counselor helps clients understand where their behavior is coming from by explaining trauma’s effects on the brain and emotional regulation, says Field, a counseling professor and coordinator of the clinical mental health track in the Department of Counseling and Human Services at the University of Colorado Colorado Springs. “[Counselors] can also help [clients] understand the real importance of basic self-care, deep breathing, good eating, exercise and that a focus on wellness on a daily basis is the best way to fight the trauma impact and arousal,” says Field, who has also counseled veterans and survivors of interpersonal violence.

A recurrent — and perhaps predominant — theme when talking about trauma-informed counseling is safety. Making the client feel safe and welcome is paramount, say trauma experts. That sense of safety starts with the environment. Counselors should make sure their offices appear warm and inviting, considering everything from comfortable seating to appropriate lighting (neither too harsh nor too dim), says Pender Baum, an assistant professor of counselor education and practicum internship coordinator at Murray State University in Kentucky.

Clients should also feel that they have some control over the counseling process. “Even if you don’t know if a client has been through trauma, you can do things as a clinician that communicate to clients that they are safe and in control of what happens in the consulting room,” says Miller, an assistant professor of counseling at South University in Richmond, Virginia, who has also worked with incarcerated women.

“Let them determine where they want to sit. Ask if they are comfortable. Give them permission to decline to answer any question they are uncomfortable with and to take breaks at any time during the intake if they start to feel uncomfortable,” she suggests. “Pay attention to body language, tone of voice and other cues of emotional distress, and respond to them. Be willing to pause during a session and encourage clients to take a breath, ground themselves or stretch.”

Establishing safety

Both Miller and Webber stress that uncovering trauma is not an automatic green light for counselors and clients to start dissecting the past.

“Establishing safety is the most important and, often, the longest stage of treatment,” Miller says. “Don’t jump immediately into reprocessing, and don’t assume that everyone needs to reprocess. And remember that if you take away someone’s primary coping skill — however maladaptive it may be — you’re leaving them with nothing to soothe themselves when their emotions run high unless you teach them more productive skills.”

Webber spends substantial time helping clients build coping skills. She says that deep breathing is the fastest, easiest and most effective way to regulate emotion, but she cautions that there is no one-size-fits-all approach to this technique. Some people like to use counting — breathing in for three or four beats, holding the breath for another three or four beats, and then slowly breathing out, perhaps for six to eight beats.

However, some clients find it stressful to focus on counting, Webber says. In those cases, the counselor and client should just focus on breathing in and breathing out. She directs clients to inhale slowly and to exhale twice as slowly, noting that the slow exhale is what calms the nervous system and helps decrease a person’s level of physical agitation.

Another factor in breathing “style” is environment. Some people need to look at something specific such as a wall to focus on their deep breathing, whereas others prefer to close their eyes, Webber says. Counselors and clients should experiment with what works best. It can also be difficult to visualize what breathing from the diaphragm means, so counselors should practice their breathing in front of a mirror so they can better demonstrate it to clients, Webber advises. Because it is hard for people to learn when they feel overwhelmed, she also emphasizes the importance of teaching deep breathing and other grounding techniques to clients when they are calm.

Another grounding technique that Webber uses is anchoring in a safe place. Before asking a client to visualize a safe place, however, she says it is important for the counselor to know whether the client has experienced sexual or physical trauma. In those cases, “safety” for the client might mean hiding behind a locked door, which doesn’t provide a healthy, calm image.

“They may not have a happy place,” Webber says. “We might have to create a brand-new place [to visualize], such as a place with no people.” Counselors can help clients visualize their safe places by asking what environments are most comfortable for them.

Webber also uses tapping as a grounding technique. Tapping is a form of bilateral stimulation that helps clients desensitize feelings of trauma and stress. Webber leads clients through deep breathing and asks them to imagine something that is agitating but not overwhelmingly traumatic. Then, she instructs them to use their hands to tap their shoulders repeatedly, alternating between left and right. After about 40 taps, she asks clients to stop and smile.

Clients can also use tapping in public if they are feeling agitated or overwhelmed. Simple and inconspicuous techniques include tapping a foot on the ground three times, lifting a heel in and out of a shoe, or simply looking left and then right repeatedly, Webber says.

Even in the midst of teaching clients coping skills and grounding techniques, their safety is never far from Webber’s mind. To avoid retraumatizing clients, she monitors their level of distress in each session, giving them a scale on which 1 represents complete calm and 10 represents overwhelming agitation. Webber begins and ends sessions with the scale. She also pauses and does a quick check within the session if the client shows signs of agitation or arousal. If the client’s distress level is too high, Webber stops and does some grounding and deep breathing with the client.

All of the professionals interviewed for this article stressed the importance of counselors receiving supervision or working in tandem with a trauma specialist if needed. “When you start to feel in over your head, you’re probably in over your head,” Miller says. “That’s a good time to get supervision or to consult with someone who has more training and experience than you.”

However, there are basic principles of trauma-informed counseling that all counselors should know, Field says. These include:

  • Psychological first aid
  • Mindfulness techniques
  • Breathing techniques
  • Grounding strategies
  • Relaxation methods

“Psychoeducation about the brain and the impact of trauma on the brain is something that all practitioners can do,” adds Field, noting that simply normalizing the effects of trauma can be enormously helpful for many clients.

Helping the helper

Another tenet of trauma-informed counseling is self-care. Immersing themselves in others’ problems and pain can take a toll on counselors, and counselors who regularly engage in trauma work face an increased risk of vicarious or secondary traumatization. According to the second edition of the APA Dictionary of Psychology, burnout can be “particularly acute in therapists or counselors doing trauma work, who feel overwhelmed by the cumulative secondary trauma of witnessing the effects.”

To continue to treat clients affected by trauma with compassion, counselors must extend some of that same consideration toward themselves. A practice of good self-care can help trauma-informed counselors to safeguard their own mental and physical health.

That is a lesson Jessica Smith, an LPC with a private practice in the Denver area, learned early in her career. “My work used to define me,” says Smith, an ACA member who specializes in addictions and trauma. “If I did a pie chart of where I found meaning in my life, three-quarters of it would have been my work as a counselor when I first started out on this professional journey, but through my burnout and recovery, I’ve learned that I am so much more than this work. I care about my clients deeply, but I also love and care about myself deeply too.

“I used to view self-care as a burden — just one more thing to do. But now I see it as an opportunity to show up more fully in my life and the lives of those around me, including my clients.”

Smith now makes self-care a regular part of her day. “I start my day with meditation, journaling and movement in the form of walking, yoga or another form of exercise. I infuse self-care throughout my day through meals, writing, music, mantras, and connections and conversations with other colleagues. I have a mantra that I say before each session, which is, ‘Help me to be a conduit or reed to transmit … messages to this person in a way that they are able to receive them. Help me to remember that I cannot fix, change or save this person and that I am only one small part of their healing journey on this earth. Give me love, give me hope and give me light.’”

The creative interventions that Smith does with clients — including movement, art, visualizations, writing and breathwork — also serve as a kind of pressure valve, she says. “I’m constantly checking in with my body during sessions, especially when I’m working with [clients who have experienced] trauma, to notice, breathe into and release any areas of tightness and tension.” Smith finds that her body reflects the tension in clients’ bodies. “[I] check in with them about their sensations, then disclose mine as well in order to help model healthy body awareness and connection.”

At the end of the day, Smith clears the office by burning sage and consciously making a decision to let go of any residual trauma or distress. When she gets home, she physically “shakes off” the day before going into the house.

“I end each day with a meditation and gratitude practice where I write down three things I am thankful for that day,” Smith says. “I stretch and do heart-opening yoga poses, then go to sleep.”

Counselors need to have self-care strategies that allow them to gain distance from their work and give them the ability to check out mentally and physically from the responsibilities of being a counselor, Pender Baum says. She has learned to literally put self-care on her calendar.

“I live by my calendar, so if it is on there, it becomes just like another required staff meeting or counseling session,” she says. “It’s not negotiable. Admittedly, I can still struggle with this one at times, [but] it’s important not to let work get in the way of your me time. Get that self-care in whenever you can. It might be closing the door for five minutes and doing some deep breathing or taking a walk around the building. Something to break up the day and get you away from your office.”

It’s also important to engage in activities that don’t have a timeline or deadline and, most importantly, that are fun, Pender Baum says. “I like to kayak, watch movies with my husband [and] read to my daughter. Others might like going for a run, reading their own book [or] soaking in a bubble bath.”

Another self-care strategy that Pender Baum emphasizes for counselors is to avoid isolation. “Developing connections sometimes can involve seeking out professional development opportunities. This helps to keep you connected to the profession, learn new skills and be around other professional counselors without hearing the traumatizing stories from clients.

“For example, just this summer, my mother — a fellow counselor educator and counselor — and I attended a training on finding meaning with mandalas. We not only learned a fantastic clinical skill, but it was very therapeutic [for us] at the same time.”

Pender Baum also stresses the importance of peer support and supervision. “It’s … important to debrief after particularly difficult cases,” she says. “Have that peer support group, supervisor [or] consultant on hand that you can engage with. Have a mentor or be a mentor to someone.”

Smith participates in two therapist support groups that meet once a month. “Since I’m in private practice, isolation can be a risk, so I do these groups as well as go to lunch or coffee with at least one friend or colleague in the field each week,” she says. “I take time off each month and no longer feel guilty about doing so as I did early on in my career. I try to do a training or workshop quarterly for self-care, connection and to nurture my inner student.”

Pender Baum says counselors need to know themselves. “Give yourself permission to experience the emotions, but also set clear boundaries,” she says. “Know your limits, avoid overtime, commit to a schedule, and recognize and change negative coping skills.”

All counselors should also be aware of the signs and symptoms of vicarious trauma, Pender Baum stresses.

“Vicarious trauma can change one’s spirituality, and this can impact the way we see the world and how we make sense out of it,” she says. “Some counselors experience difficulty talking about their feelings, anger or irritation, an increased startle response and difficulty sleeping. Others might experience over- or undereating, an ever-present worry that they are not doing enough for their clients [or] possibly even dreaming about clients’ traumatic experiences. Still others might feel trapped in their jobs, lose interest in things they typically enjoy and even [experience] a loss of satisfaction and accomplishment. Some experience intrusive thoughts related to client stories and feeling hopeless.” These are all signs that counselors need to step back and focus on self-care, she says.

Other symptoms include:

  • Chronic lateness or absence from work
  • Low motivation and an increase in errors at work
  • Overworking
  • Avoidance of responsibilities
  • Conflict at work and in personal relationships
  • Low self-image

Pender Baum also urges practitioners to listen to their peers, family members, friends and loved ones if they say they are noticing a change in them. Counselors may be unaware that they are showing signs of burnout, and feedback from others can be helpful in preventing a crash from overwork and stress.

 

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Additional resources

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

Counseling Today (ct.counseling.org)

  • “Coming to grips with childhood adversity” by Oliver J. Morgan
  • “The toll of childhood trauma” by Laurie Meyers
  • “Traumatology: A widespread and growing need” by Bethany Bray
  • “The transformative power of trauma” by Jonathan Rollins
  • “A counselor’s journey back from burnout” by Jessica Smith
  • “Stumbling blocks to counselor self-care” by Laurie Meyers

Books (counseling.org/publications/bookstore)

  • Terrorism, Trauma and Tragedies: A Counselor’s Guide to Preparing and Responding, third edition, edited by Jane Webber & J. Barry Mascari (fourth edition being published in 2018)

Webinars (aca.digitellinc.com/aca)

  • “ABCs of trauma” with A. Stephen Lenz
  • “Children and trauma” with Kimberly N. Frazier
  • “Counseling students who have experienced trauma: Practical recommendations at the elementary, secondary and college levels” with Richard Joseph Behun
  • “Traumatic stress and marginalized groups” with Cirecie A. West-Olatunji

ACA interest networks

 

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

Letters to the editor: ct@counseling.org

 

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

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.

Letters to the editor: ct@counseling.org

Counseling Today reviews unsolicited articles written by American Counseling Association members. To access writing guidelines and tips for having 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.

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.

Fostering a brighter future

By Bethany Bray February 23, 2017

In fall 2015, there were 427,910 youths in foster care, according to the most recent statistics available from the U.S. Department of Health and Human Services, marking the third consecutive year that this number has increased nationwide. Of those youths, 61 percent were removed from a home because of neglect and 32 percent were removed because of a parent’s drug use.

Given those statistics, it’s not surprising that many of the youths in foster care have trauma histories, but the process of being removed from a caregiver is traumatic for a child in and of itself, says Evette Horton, a clinical faculty member at UNC Horizons, a substance abuse treatment program for pregnant women, mothers and their children at the University of North Carolina School of Medicine in Chapel Hill. “Any kind of separation from your primary caregiver is considered trauma, no matter what the age of the child,” says Horton, a licensed professional counselor supervisor (LPCS), registered play therapy supervisor and American Counseling Association member.

For youths in foster care, attachment and trust issues, stubbornness, defiance and a host of other behavioral problems are often a result of the trauma they experienced in — and associated with the removal from — their biological homes. “The best foster families don’t take the child’s behaviors personally or as any kind of statement about them or their parenting. The kids are just coming in with what they know,” Horton says. “The best foster parents I’ve ever worked with understand that what the child does, it’s not about them [the foster parents]. The best foster families understand that [the child] is coming in with skills that they’ve developed to survive.”

Stephanie Eberts, an assistant professor of professional practice at Louisiana State University, agrees that addressing trauma should always be on the minds of counselors who work with children and families in the foster care system. “The behaviors that [these children] are showing, a lot of them make [the child] very unlikable. If we as adults can see past that, we can help the children. If we can’t, then we sometimes perpetuate the cycle they’ve been caught up in,” says Eberts, an ACA member with a background in school counseling. “It’s really important for us as counselors to help these children heal from that break they’ve had from their caregivers, the trauma they’ve experienced and the break in attachment.”

To that end, Horton says that counselors’ skills and expertise with children and families — as mediators, relationship builders and client advocates — can be integral to improving the lives of children in foster care, while also supporting their foster families and biological families, as appropriate.

“Counselors shouldn’t underestimate their power to advocate,” Horton says. “Judges, lawyers and guardian ad litems aren’t trained to understand what the child needs, socially and emotionally, and we are. You shouldn’t underestimate the power of your words and your voice to impact a vulnerable child. A child who has been put in this unbelievably complex situation needs someone to speak on behalf of his or her mental health needs.”

Ground rules for practitioners

Horton oversees the mental health treatment of children, ages birth to 11 years, whose mothers receive substance abuse treatment at UNC Horizons. Through her work, she has the opportunity to see both sides of the foster care coin. In some cases, a mother is able to make the progress needed to be reunited with her children who have been in foster care while she was in treatment. But Horton also sees mothers who are unable to maintain their recovery. In cases in which a child is being put at risk by the mother’s substance abuse, Horton must file a report with child protective services (CPS). Throughout her career, she has assisted biological families, foster families and children with the transitions into and out of foster care, and also worked with the court system and CPS.

For counselors unfamiliar with the complexity of the foster care system, Horton stresses that practitioners must be very careful to identify who, exactly, is their client. This in turn will dictate with whom a practitioner can share information, to whom they have consent to talk and who needs to make decisions and sign paperwork on behalf of a minor client. For children in the foster care system, the legal guardian is often CPS. This can become even more complicated for practitioners when a child is returned to the biological parent’s home on a temporary or trial basis. In such instances, CPS still retains custody of the child, Horton explains.

“These are very, very complicated cases, and you need to support yourself,” Horton says. “Make sure you are careful, regardless of how well-trained you are. These cases are tough — really tough. Do not hesitate to work with your supervisor [and] peers and get support.”

Eberts suggests that counselors working with families and children in the foster care system educate themselves by reading the client’s case file thoroughly and collaborating with caseworkers and the biological family (if possible) to find out more about the child’s background. If details are missing from the case file, particularly about the circumstances of the child’s removal from the biological parent, counselors should attempt to speak to a caseworker or other official who was on-site as the removal happened, Eberts says.

However, Eberts notes, practitioners should also be aware that case files often contain details that can spur vicarious trauma. “Reading some of the children’s files can be really heartbreaking. That self-care piece that we talk about so much with counselors is really, really important [in these cases],” she says.

Counselors as translators

One of the most important ways that counselors can support foster parents and improve the lives of children in foster care is to “translate” the children’s behaviors for those around them. This includes explaining what a child’s behavior means and what motivates it, and then equipping both the child and the parents (both foster and biological parents, where appropriate) with tools to redirect the behavior and better cope with tough emotions.

Eberts shares a painful example she experienced while working as a school counselor. A young student told her foster parents that she didn’t want them to adopt her. Stung by the girl’s pronouncement and taking her words at face value, the couple returned her to the foster care system for placement with another family.

“These kids have experienced a lot of loss and abandonment,” Eberts says. “[This child] was just testing her potential adoptive family — testing whether or not they were going to abandon her. The behaviors [these children display] are often protective.”

Children in the foster care system often present behaviors associated with trauma, Horton says, including:

  • Attachment issues
  • Behavioral issues
  • Nightmares
  • Anxiety
  • Separation anxiety, including trouble being alone
  • Developmental delays, including being behind in speech, language and school subjects
  • Tantrums
  • Trouble sticking to routines (as Horton points out, children in foster care often come from homes in which structure and rules were limited or nonexistent)

Despite their good intentions, foster families may not always understand a child’s behaviors, and adults may interpret a child’s symptoms of anxiety as defiance. For example, the foster parents of a child who refuses to eat vegetables or who puts up a nightly struggle over going to bed may feel the child is being stubborn or testing their authority. In reality, Horton explains, the child may never have been fed vegetables or slept alone before. Misunderstandings can be further compounded when a child comes from a different culture or socioeconomic background than his or her foster family, she adds.

Sarah Jones, an ACA member and doctoral student in counseling and student personnel services at the University of Georgia, agrees. Jones and her wife are foster parents. Over the past five years, they have had 20 different children, all under the age of 7, stay in their home. Jones says the vast majority of children she has seen in the foster care system in Georgia have come from low socioeconomic backgrounds. It is common for these children to present insecurities about food, shelter and other basics, she says.

Foster parents and counselors alike “can give [these children] a glimpse of what the world can be. It can be a place where there is enough food, where there is enough love,” says Jones, who presented on narrative techniques with college students in foster care at ACA’s 2016 Conference & Expo in Montréal.

At the same time, Jones stresses that counselors should avoid assigning blame to the biological parents, the child or a system in which caseworkers are vastly overworked and underpaid. Jones thinks of it this way: The moment when a child is removed from his or her home is the low point for the biological parent or parents, but things will not necessarily stay that way.

“It’s like we’re taking a snapshot of someone in their worst-case scenario and making generalizations for their entire lives. … Sometimes we equate that to [these parents] not loving their kids, but sometimes love is not enough,” Jones says.

Counselors should also be aware that CPS usually tries to exhaust every possibility of having children placed with a biological family member before they are placed in foster care, Jones says. In some cases, children in foster care have parents and relatives who have died, are incarcerated or involved in other situations that make them unable to care for their children. “To be in the foster system, it’s not a problem that can be fixed in six months [or a short period of time],” she says. “It means that the biological parents don’t have a network that could take the child.”

Responding effectively

B.J. Broaden Barksdale, an ACA member and LPCS in Katy, Texas, has worked with children and families in Texas’ foster care system for 18 years. Initially she did home monitoring and assessment of foster families and then transitioned into working as a therapist with children and families in the system.

The behavioral issues with which children in the foster care system often struggle can be accompanied by tantrums, outbursts and emotional flare-ups, Barksdale says. She likes to use trauma-focused cognitive behavior therapy and the Trust-Based Relational Intervention (TBRI) to provide these children and their families with tools for better functioning.

TBRI’s four-level response method helps caregivers to redirect the child’s behavior while maintaining a connection and using the least severe response possible, Barksdale says. Counselors can use this method in their own work with foster children and in coaching parents and caregivers on how to use the method at home.

Level one: Playful engagement. To start, a caregiver or other adult should remain playful and light with the child. For example, if the child comes home from school, slams the door and drops his or her backpack on the floor, a caregiver could respond with, “Whoa! What’s this?” or some other lighthearted remark, Barksdale suggests. Then the child could be given a do-over. Or, if a child makes a demand of an adult, such as “Give me that!” the reply could be, “Are you asking or telling?” If the child doesn’t have the right words to ask appropriately, a counselor or parent can phrase the question and have the child repeat it. Regardless, Barksdale says, the key is to maintain a kind, playful tone and to redirect the child to keep the situation from escalating.

Level two: Structured engagement. If a child does not respond to an adult’s initial playful response, the next step is to offer choices. If a child is refusing to go to bed, give the child a voice and ask what would help him or her get to bed on time. For example, “How about turning off the TV 30 minutes earlier? How can we compromise?” This empowers the child to choose, avoids a power struggle and teaches the child compromise and conflict resolution, Barksdale says.

Repetition and consistency are key, she says. “The repetition is retraining their brain. … Giving them choices helps them learn to make choices,” Barksdale says. “And once they do it, praise the heck out of them. Try to always find something to praise, even if it’s as small as coming home without slamming the door. It’s all in how you say it — ‘We don’t hurt the dog’ instead of ‘Haven’t I told you not to do that?’”

Barksdale emphasizes that the adult should also consider the bigger picture of the child’s day. Has the child been overstimulated or particularly busy? Does the child need some quiet time, a drink or a snack, or something else?

Level three: Calming engagement. If a situation escalates to this level, the child should be given time to pause, cool off and think things through. Barksdale encourages foster parents to designate a space in the home for this very purpose. It should be a safe, comforting space where a child can spend time alone, relax and be quiet while an adult is nearby, she says.

Level four: Protective engagement. When a situation escalates to the possibility of violence, a caregiver can use accepted restraints to calm the child (but only if trained to do so through the foster care system or another agency). The adult must stay calm and reassuring and should remain with the child until he or she is calm enough to talk through the situation.

“These kids are combative about authority, hypervigilant and don’t trust anyone,” Barksdale says. “You have to teach them what they have never learned. You have to be compassionate and get them to trust you. If you don’t build that trust, that felt safety, you can’t move forward.”

In addition to providing consistency, it is essential to address behavioral issues immediately as they unfold, Barksdale says. Through TBRI, she uses the acronym IDEAL to teach this to parents:

I: Respond immediately.

D: Directly to the child, through eye contact and undivided attention, with a calm voice. Barksdale says she often gets down on the floor with younger children to better connect and because it makes her appear as less of an authority figure.

E: In an efficient and measured manner, with the least amount of firmness required.

A: Action-based, by redirecting the child and providing a do-over or giving the child choices. This could include role-play, in which the adult acts out two responses that the child could choose, one of which is inappropriate.

L: Level the response to the behavior, not the child. Criticize the behavior as being unacceptable, but not the child, Barksdale explains.

“You want to give them voice and build trust,” she says. “If they understand that you’re trying to be in harmony with them, they engage. Remember that these kids may have had no relationships, no attachment, since birth. … If there’s relationship-based trauma [in the child’s past], that can only be healed through forming healthy relationships.”

Eberts agrees, noting that counselors should consider the backgrounds of the children they are working with and the reasons they were removed from their biological homes. Counselors can then use that information to identify the child’s major needs.

For example, Eberts worked with a foster family that included an 8-year-old boy who was placed in foster care when he was 2. His biological parents had issues related to drug use and were running a methamphetamine lab in the home when he was taken from them. The boy was prone to outbursts that sometimes became violent.

“For the first two years of his life, he was not getting the kind of attention and care that he needed,” Eberts says. “We used that information to help his foster parents understand that when he needs something, he won’t ask for it in a way the foster parent might expect. … He did not have the attachment needed to connect with other people.”

Eberts worked with the child on building connections with people and trusting that his needs would be met. She used play interventions to help the child learn to express himself, identify emotions and process his frustration. Eberts also equipped the foster parents with tools to de-escalate his tantrums, including recognizing the cues the child gave leading up to his outbursts, and calm, consistent methods for responding when outbursts took place.

“He was very challenging, but things did get better,” Eberts recalls. “It was hard work and took a long time. [The foster mother] had to work on herself quite a bit to understand when he was starting to escalate and how to de-escalate him [by] using a calm voice and helping him to self-identify emotion … in a way that wasn’t combative or defensive. He wasn’t student of the year by the end of the year, and he still struggled with attachment, but the skills that the foster mother had learned helped a great deal. He was on the road to having a much better life experience.”

“He was violent because he was sad and he didn’t know what to do with it,” Eberts says. “These are kids who have so many emotions, they don’t know what to do with them. They don’t know how to express them.”

Tips for helping

Counselors can keep these insights in mind when working with children and families in the foster care system.

Regression is common. For children who have experienced trauma and instability, progress will often be accompanied by spurts of regression. For example, a child who is potty trained may suddenly start having accidents when moved to a new foster home, Horton says. Counselors should coach foster parents not to get discouraged if a child regresses.

“Help the family understand that this will pass. It’s part of the road,” Horton says. “We have to remind people that this is actually common. It’s all very new and confusing to [the child]. All of us regress when we’re under stress, and kids do too.”

Regression can also be expected when children in foster care phase into a new developmental stage, such as the onset of adolescence, Eberts says. “The trauma that they’ve experienced in life has to be reprocessed at every developmental milestone,” she explains. “When they hit adolescence, they’ll have to reprocess it from an adolescent perspective, then as a young adult. So if an 8-year-old makes progress, they can and will regress when they hit 12. They’re processing things from a different developmental perspective.”

Meet children where they are. Many children in the foster care system will lag behind their biological age developmentally, from emotional maturity to speech skills. Counselors should tailor their therapeutic approaches to a young client’s level of development, not the age on his or her file, Eberts says.

“A child who is 10 may still be a great candidate for play therapy because, developmentally, he is really around 7 years old,” she says. “The intervention has to be aligned with the child’s developmental age.”

Keeping that in mind, the expressive arts and tactile interventions such as sand trays and art, dance and movement therapies — in other words, methods other than talk therapy — can be particularly useful with children in the foster care system, Eberts says.

“Keep in mind that you have to meet the child where they are developmentally. That is the most important thing,” Barksdale says. “Expectations for a child who has experienced trauma need to be realistic.”

The importance of structure and routines. If children are coming from a background ruled by instability, it is helpful for counselors to work with foster families on establishing routines and clear expectations. “Make sure there are as few surprises as can be,” Jones says.

For example, it can provide a sense of security for the family to have a movie night every Saturday or to eat dinner together at the same time each evening. Nighttime can be particularly troubling for foster children, so establishing an evening routine and sticking to it — such as brushing teeth and then reading a book together — can be helpful, Jones adds.

Horton suggests that counselors work with foster families to create and post a list of age-appropriate house rules and a daily routine or calendar. If the foster child is too young to read, these lists can be illustrated with pictures. This becomes even more effective if the counselor has access to both the foster and biological families so that the lists can be posted in both homes, Horton says. When possible, the same can be done with a compilation of photos of the child’s biological and foster families, she says.

Prepare for transitions. Transitions both large and small, whether they encompass switching schools or simply transitioning from playtime to bedtime, can be hard for children in the foster care system. Counselors can suggest that foster parents provide plenty of gentle, advance notices that a transition is coming, such as 30 minutes, 15 minutes and five minutes before a child needs to finish playtime to go grocery shopping with the family, Barksdale says.

Established routines can also help in this area, she adds. “Bedtime should be at the same time every night if at all possible. If done repeatedly, the child knows what’s coming next. It helps with comfort, consistency and felt safeness,” Barksdale says. “The one-on-one attention helps with relationship-building, and once trust is built, it’s easier to redirect the child.”

Goal setting and journaling. In the counselor’s office, engaging in dialogue journaling and goal-setting exercises can be helpful for youths in the foster care system, Jones says.

In a dialogue journal, the client and counselor write messages back and forth (younger clients may draw instead of write). The journal can help spark conversation and get the client thinking in between sessions. “A lot of times they don’t know how to talk about their past,” Jones says. “[Through the journal], they can talk about something that happened in their life. Maybe it’s, ‘I wasn’t able to have dessert because I didn’t finish my broccoli.’ Then you can transition into a conversation about how that is different from their past home.”

Goal setting can also be a useful way to connect the past, present and future with young clients, notes Jones. For example, a counselor might work on building a young client’s social skills by encouraging the client to set a goal of talking to one new person at school in the coming week. The counselor would talk through the steps the child could take to achieve the goal and ask the child how he or she made friends in the past at previous schools. “You’re showing the child that they already have those skills,” Jones says. “They just need to use them in a new place.”

The power of pictures. Horton often creates picture albums for her young clients who are transitioning between foster care and home placements. She contacts adults the child is acquainted with to ask for photographs of biological relatives, foster family members and other important people in the child’s life. She looks at the book with the child at every counseling session because it serves both as a conversation starter and a way to remember loved ones, she says.

“Sometimes we have to help create the story that helps the child make sense of what happened,” Horton says.

Coping tools and self-regulation. Many children in the foster care system can be flooded with anxiety and strong emotions, including anger, Horton says, which can make self-regulation exercises, from mindfulness to breathing exercises, particularly helpful. Horton often brings bubbles to counseling sessions. She shows the children how to make big bubbles — which also teaches them how to take slow, deep breaths, she says. In the case of another young client, self-regulation included getting outside. His foster family had a trampoline, and they would all go outside and jump together. This made a difference because rather than just shooing him out the door, they stayed with him to work through his anger as they jumped, Horton says.

Barksdale uses a tool in session that serves as a jumping-off point to talk about self-regulation with clients. It is a wheel with an arrow that clients can move to different colors to indicate how they are feeling. “If you’re feeling blue and tired, what can you do? Get a snack or drink some water. If you’re in the red and really hyped up, what can you do? Count backward and breathe,” Barksdale says. “If you’re feeling anxious and tense, what does your body feel like? Learn to identify that.”

Be honest and talk it through. Be honest with the child while also giving him or her the space to process what is happening, Jones says. “For a few weeks, it feels [to the child] like you’re on vacation and you’re at someone else’s house. As they start to feel more comfortable, the feelings start to come. With that ease also comes an onslaught of feelings about what they’re giving up and missing,” Jones says. “It’s important to recognize how difficult it is, but at the same time saying, ‘You are not alone.’”

“Tell them, ‘There are a lot of people who love you, and they’re doing the best they can right now,’” she says. “We [Jones and her wife] really believe in talking about what’s happening.” Jones says it is important for counselors and foster parents to “talk about how your family is dynamic, and this is what’s happening right now.”

When it’s time to let go

As a foster mother, Jones is all too familiar with working to form bonds and relationships with children in her care despite knowing that they may soon transition back to their biological families. This break can be quite painful for foster families, she says.

“It’s important for counselors to give families a space to grieve,” Jones says. “There was a period of time when our family had two significant losses back to back. A child we had from birth transitioned to her mother after 16 months. Then, less than three months later, a child transitioned from our home into her father’s home and, less than one week later, died from natural causes. The grief associated with these experiences impacted every member of our family — even our dog was acting depressed. My counselor gave me a space to experience very big and painful emotions, then eventually helped me make meaning from my experiences.

“Reminding foster parents that the amount of pain they are experiencing is likely equal to the amount of love given to a child in need is also a powerful reminder. It hurts because it mattered, and if it mattered to us, it likely made an impact on a youth’s life. And that’s why we work as foster parents — and as counselors.”

 

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Related reading

See Brian J. Stevenson’s article “Developing a Career Counseling Intervention Program for Foster Youth“ in the June issue of the Journal of Employment Counseling: http://bit.ly/2r6gFUj

 

 

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Foster care: By the numbers

  • For 2015, the median age of the youths in foster care was 7.8 years old. The median amount of time in care was 12.6 months and the mean was 20.4 months; 53,549 children were adopted with public child welfare agency involvement.
  • Between 2014 and 2015, 71 percent of states reported an increase in the number of children entering foster care. The five states with the largest increases were Florida, Indiana, Georgia, Arizona and Minnesota.

Number of children in foster care in the U.S. on Sept. 30

2015: 427,910

2014: 414,429

2013: 401,213

2012: 397,301

2011: 397,605

Reasons for removal from a home and placement in foster care (2015)

Neglect: 61 percent

Drug abuse of a parent: 32 percent

Caretaker’s inability to cope: 14 percent

Physical abuse: 13 percent

Child behavior problem: 11 percent

Inadequate housing: 10 percent

Parent incarceration: 8 percent

Alcohol abuse of a parent: 6 percent

Abandonment: 5 percent

Sexual abuse: 4 percent

Drug abuse of the child: 2 percent

Child disability: 2 percent

Reasons for discharge from the foster system (2015)

Reunification with parent or primary caretaker: 51 percent

Adoption: 22 percent

Emancipation (aged out): 9 percent

Guardianship: 9 percent

Living with other relative(s): 6 percent

Transfer to another agency: 2 percent

 

Source: U.S. Department of Health & Human Services Administration for Children & Families, acf.hhs.gov

 

 

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To contact the counselors interviewed for this article, email:

 

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

Letters to the editor: ct@counseling.org

 

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

A scar is not a wound: A metaphor for counseling

By Peter D. Ladd November 10, 2016

In the client-counselor relationship, describing traumas from past experiences can reveal unresolved suffering in which a client’s beliefs, emotions and behaviors are filled with deep negative images. Ideally, clients will share their trauma with therapists and how images from the past continue to affect them. By describing their trauma, many clients can normalize past experiences and are able to face future traumas with more positive attitudes.

However, as counselors, we realize how accessible these traumas become for clients who slowly drift back into old patterns when new trauma enters their lives. New trauma that is even remotely similar to past trauma can resurrect old beliefs, trigger negative emotions and generate compulsive patterns of behavior. The question becomes, how do counselors stop clients from drifting back into old traumatic patterns when new traumas enter their lives?

 

Using metaphors

One successful possibility is the use of metaphors. According to Judy Belmont, metaphors allow counselors to unlock a client’s way of thinking by creating flexibility and evoking emotion. They allow clients to visualize their thoughts and connect them to their feelings.

Neurologically speaking, metaphors allow the neuropathways of the brain to realign in a way where thinking and feeling bring into account a similar picture from a past incident. This leads to a more comprehensive understanding of experiences such as trauma, abuse, loneliness and loss.

Let’s look at one such example with elements that most people around the world would understand — namely, wounds and scars. It may be impossible to get through life without experiencing some form of physical or psychological wound that affect a person’s everyday experience. You trip and fall down the stairs, you are in an accident, someone close to you dies … these are examples of wounds that hopefully will heal. If they do heal, many times you are left with a scar that reminds you of the incident that took place.

But there can be confusion over the healing process and how the person perceives his or her wounds developing into scars, especially if they are psychological scars. My hope is that the metaphor “a scar is not a wound” will help clarify this healing process with an emphasis on psychological healing.

42 QmF1bUhlcnpJK0YrUysyTy5qcGc=When someone has a wound, the healing process can involve suffering that may feel worse than the initial acquiring of the wound. However, most people find this experience tolerable based on a belief that a certain level of suffering is required to allow the wound to heal. In turn, people with a healing wound assume that they are “on the mend.”

In many cases, a healed wound may leave a scar as a reminder that successful healing has taken place. Although the scar may be ugly, annoying, a topic of conversation or not as favorable as regular tissue, it is still an image of success signifying that a wound has healed. If the scar begins to throb or becomes painful at a future date, many people still tolerate it as a reminder of successful healing. They do not hold the scar to the same traumatic standard as they do the original wound.

At this point, it may be safe to say that, metaphorically speaking, a scar is not a wound.

 

An overview

When helping clients understand their past traumas, it may benefit therapists to describe these traumas as open wounds that need to heal. In mental health, when someone experiences a past mental wound, the healing process can be quite similar to that of a physical wound. For example, in therapy, when exposing past mental wounds, the associated suffering may feel worse than the suffering from the original traumatic experience.

Furthermore, mental health clients can confuse the difference between necessary and unnecessary suffering with these wounds. When experiencing a physical wound, it seems much easier to accept suffering as necessary. A mental wound may be harder to accept or tolerate, however. Even when clients work through the suffering associated with mental wounds, they may remain anxious about the possibility of the wound returning.

Many clients in mental health are at a disadvantage when it comes to the healing process, in part because they cannot look at their wounds and watch them heal. Instead, they must trust in the therapeutic alliance between client and counselor to form a belief about how the mental wound heals. Neither can these clients look at their wound and visualize growth and change.

For therapists who find meaning in the power of images, this may be an appropriate time to introduce the metaphor “a scar is not a wound” to help clients visualize their healing. When normalizing past traumas with clients, therapists can describe trauma as an open wound that needs to heal. Eventually, the client and therapist may want to discuss turning wounds into scars.

A scar can be used as a metaphor that reminds clients of past open wounds but in a positive manner. Helping clients transform wounds to scars is a metaphorical way of making past trauma meaningful and positive. Instead of clients looking at new trauma as a return to an open wound, they can use the metaphor of a scar as reassurance that they have gained resilience for future traumas in their lives.

This begs a question: Can mental scars be more than reminders of past wounds? Can they be viewed as products of successful healing? The scar metaphor creates growth and change by using the natural process of healing as a model for mental health. Such a model can be used when future traumas that are even remotely similar to those from the past might suggest a traumatic relapse. Recognizing the difference between a scar and a wound can stop a continued drift into old beliefs, emotions and behaviors.

The scar/wound metaphor is a clear and simple way of reminding clients with posttraumatic stress disorder, secondary traumatic stress reaction, apathy, abuse, loneliness or loss that traumatic experiences can sometimes create resilience. Therapists can help clients learn from their scars. They can be symbols of successful healing. They can be viewed as a source of wisdom, similar to what is found in many survivors of physical wounds. Scars are not wounds, and when a new trauma is experienced, counselors can help clarify the difference.

This metaphor follows a growth and change model for treating clients. Ironically, it also follows a medical model by explaining the process of healing that takes place when doctors treat a physical wound. More important, it references the natural healing process, whether mental or physical.

This provides clients with a more holistic view of healing. It also allows clients to rely on a schemata or map of healing that they know and understand. Finally, it puts traumas in a different light in which necessary suffering is viewed as a natural process that can have positive results.

 

Multicultural implications

Metaphors are used in most cultures, making them especially useful in the field of therapy. Universal themes that transcend cultural differences give certain metaphors more reliability and validity. The “scar is not a wound” metaphor leaves little room for cultural misrepresentation.

Furthermore, the image of a scar is a universal concept that has deep meaning from a cultural perspective. For example, some African cultures create scars on their faces and bodies as a statement of rank, courage or pride in their communities. The scar may signify going through some difficultly and coming out the other side intact.

The “scar is not a wound” metaphor, therefore, becomes multicultural because scars and wounds are viewed as universal phenomena that can be interpreted in many different ways, with most of these interpretations symbolizing a sense of healing.

 

Group supervision

Because supervision and instruction are often provided in a group format, the “a scar is not a wound” metaphor can encourage more dynamic and inclusive results. Some examples of questions for groups are:

1) When is an effective time to bring up the “a scar is not a wound” metaphor when discussing the group members’ past traumas?

2) What were your experiences of having a wound turn into a scar, either physically or mentally?

3) What are your beliefs regarding your physical and mental scars?

4) Do you know of any culture that views scars as a sign of success when working through a difficult time?

5) Do you think it is ethical to use examples from physical healing to describe mental healing?

 

Potential problems

For those looking for a more scientific explanation of healing, the “a scar is not a wound” metaphor may be viewed as too conceptual, with little use of facts to back up one’s description. This may be especially true with new supervisees who are looking for factual definitions for such phenomena as trauma, DSM-5 disorders and other natural scientific concepts that make up the lexicon of mental health counseling.

There also might be those who question whether clients who have experienced trauma want to look at their scars in such a positive light. These clients may view their scars as grim reminders of past traumas that should be buried and not revisited. They may view these scars with failure and embarrassment and not appreciate the intrinsic value in seeing scars as a “success story.”

In addition, those who are looking for a more linear, step-by-step approach to healing may find such a metaphor too esoteric and not fitting for mental health counseling. These clients may want cause-and-effect answers that help control their anxiety about the possibility of future traumas.

Some counselors may find the use of the metaphor too nondirective, preferring more control over the information they share with their clients. In addition, it may not appeal to those therapists who hold little interest in the workings of the unconscious mind.

 

Additional applications

This metaphor can work well with groups whose members have suffered “wounds” that have produced negative results in their lives. For example, many individuals struggling with addiction have a history of trauma ranging from intrapersonal to interpersonal and leading them to their individual addictions. Some of these traumas remain open wounds that go even deeper than the addictions themselves. Blame, shame and low self-esteem may haunt these clients. Their open wounds have not turned to scars and may be the major cause of any relapse that takes place. Sometimes the open wounds become their own emotional addictions. In fact, healing the individual’s physical addiction may require healing his or her emotional addiction. This phenomenon can take place in both addictions counseling and mental health counseling.

In addition, counselors can build a repertoire of other metaphors grounded in the “scars are not wounds” metaphor. For example:

  • “You can’t see the picture while inside the frame.” — A metaphor for a therapeutic alliance
  • “A counselor should focus on trauma not drama.” — Staying with the counseling process
  • “It is the broken helping the broken.” — Getting away from counselors as experts
  • “No client is as sick as his or her file.” — Looking for possibilities, not facts
  • “It takes more courage than brains to be an effective counselor.” — Being a model for change

 

 

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Peter D. Ladd is a licensed mental health counselor and the coordinator of the graduate mental health counseling Program at St. Lawrence University. His interests include existential and phenomenological counseling and conflict resolution. He has written 10 books from this perspective. Contact him at pladd@stlaeu.edu.

 

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