Tag Archives: trauma

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.

Addressing ethical issues in treating client self-injury

By Julia L. Whisenhunt, Nicole Stargell and Caroline Perjessy July 24, 2016

AuthorsAs professional counselors, we enter this field with a desire to understand and help others. There comes a time in every counselor’s career, however, when intellectual understanding is overpowered by the need for empathic understanding. This is particularly true when counselors work with clients who intentionally cut, burn, scratch, hit or otherwise injure themselves.

Jennifer Muehlenkamp and colleagues found that this coping skill, known as nonsuicidal self-injury (SI), may be used by as much as 18 percent of the general population. Furthermore, Laurie Craigen and colleagues found that as many as 39 percent of adolescents may self-injure. It is important to note that SI is separate from socially sanctioned body modification practices (e.g., piercings, tattoos), substance use or physical fighting, which can also seem intentionally harmful but have different underlying purposes.

Purpose of SI

For those who do not purposefully inflict physical harm on themselves, the concept of SI can be both foreign and confusing. As counselors, we need to know that SI works for some people, most often to help them manage intense and often painful emotions. In fact, David Klonsky, a pioneer in SI research, found that emotion regulation is the single most common function of SI. Emotional pain is linked with physiological arousal (e.g., pounding heart, headache), and SI can ease this tension, channel the pain and bring arousal to a bearable level.

Researchers such as Klonsky, Muehlenkamp, Janis Whitlock, Brianna Turner, Alexander Chapman and Brianne Layden have also examined other functions of SI. For example, SI can serve as a method for transforming emotional pain into physical pain, which can be easier to cope with for many people. SI can serve as a way to validate feelings and create a visual representation of the pain within them. Some people who self-injure may do so to cope with feelings of dissociation or depersonalization — to help themselves feel “real” or “alive” again. This is especially relevant for people who feel numb because of depression or trauma. SI can be used to vent anger privately or to channel anger toward the self as a form of punishment.

Finally, although less common, SI can serve as a means of communicating with or influencing others. Despite popular stereotypes, SI is rarely meant to be intentionally manipulative. Most often, clients who self-injure for this reason do so because they do not know more effective ways of communicating their needs and distress. In fact, the majority of clients who self-injure do so in private and are very secretive about it. Admittedly, some people self-injure to either intentionally or unintentionally influence others, but this is not the primary motivation for most clients. Consequently, assuming malicious intent behind SI can be grossly invalidating to clients’ experiences and can severely damage the therapeutic relationship.

Although the motivations for SI are complex and unique for every individual, the lay community has often equated SI with suicide. Whitlock and colleagues found that as many as 60 percent of people who self-injure may experience suicidal thoughts or behaviors. Although SI is a strong predictor of suicide, a large portion of people who self-injure do not struggle with suicide.

Several differences exist between SI and suicide regarding intent, means, frequency, severity, and emotional antecedents and consequences. Researchers such as Chapman and Katherine Dixon-Gordon have found that the emotions experienced prior to and following SI and suicide attempts are largely different. Furthermore, Muehlenkamp and Peter Gutierrez found that people who self-injure are often able to identify more reasons for living than are people who are suicidal. In fact, for some people, SI may serve an anti-suicidal function that is life preserving.

Counselors working with clients who self-injure are likely to encounter some ethical dilemmas regarding safety concerns and duty to warn/protect. With that in mind, we want to discuss some ways for counselors to address common ethical concerns that tend to emerge in this type of work. This list is not comprehensive, however, so counselors should use an established ethical decision-making model and consult or seek supervision as necessary.

Counselor values

Although counselors are trained to nonjudgmentally join with their clients, counselors may have intense reactions to SI. Doreen Fleet and Rita Mintz found that shock, sadness, anger, anxiety, frustration and diminished professional self-confidence are common responses to SI.

It is important to remember that the therapeutic relationship can be damaged beyond repair if clients feel judged. Even if counselors temper their initial reactions and support clients who self-injure, other counselor values can be damaging to the client and the therapeutic relationship. For example, it is unhelpful to assume that every client who uses SI needs to be hospitalized. We will discuss safety assessment later in this article, but counselors should remember that SI and suicidality are not equivalent.

Some counselors might feel that a contract specifying no SI would encourage clients to use healthier coping skills, but that can stem from a counselor’s anxiety surrounding the behavior and can lead to clients feeling judged by the one person who is supposed to be nonjudgmental. Moreover, SI works as a coping skill for some clients, and asking them to give up their most effective coping skill in the absence of other ways of coping can leave them feeling scared and helpless. In addition, nonharming alternative behaviors (e.g., snapping a rubber band, using a red water-soluble marker) may reduce risk, but they are not effective ways of addressing the underlying mental health issues.

Out of concern, some counselors may lecture clients on the dangers of SI and the fear that SI evokes for loved ones. Although psychoeducation can be used very effectively with clients who self-injure (e.g., dangers and wound care), there is a fine line between psychoeducation and lecturing. Many people who use SI experience self-imposed shame and guilt or have it imposed on them by others. Consequently, lecturing clients on the consequences of SI or otherwise attempting to convince clients not to self-injure can be harmful.

Similarly, chastising clients for doing permanent damage to their bodies is also unhelpful because SI is commonly a way for some people to connect with their bodies and find physical and emotional relief. It can also be unhelpful to insist on seeing a client’s wounds. If the client would like to show you his or her wounds, that can be therapeutic in itself. However, we are not medical doctors, and we should refer physical assessments to someone who is properly trained.

Overall, counselors should work toward empathic understanding of SI and reduce stereotypes or countertransference in the relationship. Working with clients who self-injure presents unique considerations for clinicians, who must manage their own reactions and beliefs about SI while simultaneously providing sound therapeutic care. Supervision, consultation and treatment teams are key sources of support and monitoring when working with these clients.

Confidentiality

The issue of confidentiality can be complicated when working with clients who self-injure, especially if those clients are minors. Confidentiality and privacy should be explained clearly in informed consent, which is an ongoing process.

At intake, or when SI is disclosed, counselors should explain techniques and interventions that will be used specifically to address SI. Counselors should also be very clear about the duty to protect and how SI might lead to mandated reporting, such as if the client develops suicidal intentions or if SI results in a major health risk (e.g., large, infected wounds).

If the client is a minor and caregivers are aware of the SI, an open discussion should occur to determine what types of information will be shared (e.g., types of interventions, progress toward goals) and how this will be shared with caregivers (e.g., privately over the phone, after session with the client present). If the caregivers of a minor are not aware that the client is using SI, counselors might need to disclose this information to parents because of the possibility of foreseeable harm. Again, however, it is important for the client to feel empowered throughout the treatment process, especially when the counselor must notify parents or loved ones.

Foreseeable harm and safety planning

Although it is important to temper counselor anxiety and methodically work through the counseling process with clients who self-injure, it is also important to actively monitor and continually assess client suicide risk. Clients sometimes minimize their use of SI, and counselors must astutely tune in to the serious nature of this behavior, understand the possibility of increased harm in the future and put adequate interventions in place.

Relatedly, clients might disclose SI before they are ready to work toward goals related to the behavior. Counselors must explore the paradox between autonomy and nonmaleficence, constantly assessing for the point at which risk outweighs the client’s readiness to change. As mentioned previously, it is generally not helpful to ask clients to stop self-injuring in the absence of other effective coping skills. So, part of this process typically involves diminishing risk while simultaneously enhancing the client’s other strengths and coping skills.

Ongoing formal and informal suicide assessment should be part of the therapeutic process. However, it is critical that counselors do this in a way that is neither assumptive nor judgmental. It is also helpful to develop a safety plan with all clients who self-injure. Clients can
use the safety plan during times of distress, regardless of whether suicidal ideation is present. A major component of providing care to clients who self-injure involves the counselor’s efforts to ensure the appropriateness of services through consistent consultation, supervision and referrals.

Assessment of SI and suicide

Assessment of SI begins at intake. We believe it is important to ask all new clients about their history of intentional SI. There are a number of assessment instruments for SI, some of which screen for SI, some that monitor risk of suicide and some that assess the functions of SI. Examples include Kim Gratz’s Deliberate Self-Harm Inventory, Matthew Nock and colleagues’ Self-Injurious Thoughts and Behaviors Interview, Marsha Linehan and colleagues’ Suicide Attempt Self-Injury Interview, and Catherine Glenn and David Klonsky’s Inventory of Statements About Self-Injury. As is the case with any therapeutic issue, counselors should document their use of established assessment instruments, consultation or supervision, and a reputable decision-making model to uphold proper standards of care.

In consideration of the elevated risk of suicide and the sometimes conflicting feelings about life and living that some clients who self-injure may experience, it is important for professional counselors to use recursive suicide risk assessment practices. Without assuming that clients who self-injure are suicidal, counselors should conduct suicide risk assessments at intake, at Branding-Images_injuryperiodic intervals and as indicated throughout the therapeutic relationship. Counselors should remember that suicide risk assessment involves more than asking a quick close-ended question. Rather, it should involve use of a reliable and valid instrument and should include dynamic, ongoing discussions about stress, coping and ideas about living.

When working with clients who self-injure, we ask counselors to remain attuned to the risk factors and warning signs of suicide so that they can respond most appropriately if risk elevates. Safety plans (as opposed to no-harm contracts) are an effective way to build the counseling relationship and minimize client risk. At a minimum, safety plans include identification of warning signs, internal coping strategies, positive distractions, people to ask for help, professionals/agencies to ask for help and ways to make the environment safer.

Competence

As professional counselors, we are charged with practicing only within the boundaries of our competence based on education, training, supervised experience, state and national professional credentials, and appropriate professional experience. However, clients who self-injure usually present with multiple treatment issues that are complicated for both novice and seasoned clinicians to conceptualize.

Clients who self-injure often have trauma and abuse histories. Consequently, they can also struggle with eating disorders, poor body image, personality disorders, anxiety, depression and suicidal ideation. Because clients who self-injure may present with complex symptomatology and even acute distress, counselors may doubt their clinical competence and ability to meet the therapeutic demands of this client population.

Efforts to improve feelings of competence can be addressed in a variety of ways. First, we can encourage counselors to remember that the best way to understand clients’ lived experiences is to create a safe context in which clients feel free to share their stories. Counselors can promote clients’ sense of safety by exhibiting humanistic qualities such as unconditional positive regard, which can both strengthen the therapeutic relationship and convey understanding and acceptance of the client.

Next, counselors engaging in ongoing supervision and consultation can improve their clinical skills related to working with this population. Discussing clients who self-injure, in supervision or consultation contexts, provides counselors with new and different perspectives on their work, which can help them modify their treatment planning and clinical interventions. Consultation and supervision also offer counselors opportunities to reflect on how they feel toward their clients. Considering how strongly our value systems shape our work with clients, this is an invaluable exercise.

It is also imperative that counselors who work with this population review the existing literature on SI, seek continuing education on SI and remain current on emerging SI research. Competent counselors should practice treatment strategies that are evidence based and well-grounded in the literature, and access reputable resources, such as those stemming from the International Society for the Study of Self-Injury.

Finally, in situations in which clients are not progressing or a therapeutic impasse cannot be resolved, competent counselors should understand how and when to refer to another provider. Often, when counselors are unable to promote a strong therapeutic alliance or further treatment goals, it is the result of a lack of training or experience that can be remedied through additional training, supervision and consultation.

Evidence-based practices

SI is a complex treatment issue and, for obvious reasons, counselors may feel ill-equipped to effectively intervene when clients self-injure. However, just like with any treatment issue, effective intervention begins with having a safe and nonjudgmental relationship. This is not to say that knowing the complexities of SI and how to intervene appropriately are unimportant. Rather, we hope readers will remember to start with the relationship and use interventions and treatment strategies that are grounded in the literature.

In the next section, we provide a brief introduction to a few therapeutic strategies that have shown promise with clients who self-injure. It is important to note, however, that no specific treatment interventions have proved largely effective for the treatment of SI. So, counselors often rely on theoretically grounded interventions and those proposed by leaders in the field of SI. For a more detailed yet succinct review of evidence-based practices in the treatment of SI, see the ACA Practice Brief on nonsuicidal self-injury by Julia Whisenhunt and Victoria Kress (see counseling.org/knowledge-center/practice-briefs). The practice brief provides references to a number of researchers who have

examined SI intervention. Additionally, we recommend a recent publication by Catherine Glenn, Joseph Franklin and Matthew Nock, who examined the evidence base of SI treatments for youth and rated their effectiveness using the Journal of Clinical Child and Adolescent Psychology standards level system.

Individual interventions: Dialectical behavior therapy (DBT), created by Marsha Linehan, improves emotion regulation skills and intrapersonal awareness by challenging and modifying one’s cognitions, emotions and behaviors. As mentioned earlier, emotion regulation is the single most common function of SI, so learning to regulate emotions in healthier ways can decrease SI behaviors. DBT interventions are most successful when clients feel supported and accepted by their counselors and when counselors believe in their clients’ ability to change. The evidence base on DBT for SI is still limited, and some results are conflicting, but DBT may be useful for managing some of the emotion dysregulation and alexithymic aspects of SI.

Because of the maladaptive and distorted cognition seen in many people who self-injure, cognitive interventions may be well-indicated. Both David Klonsky and Nadja Slee independently suggest that cognitive therapy has been found to be most effective when focusing on the specific SI behavior and on emotion regulation skills. Problem-solving therapy, a type of cognitive therapy, may be effective when combined with cognitive, behavioral and interpersonal interventions. However, Jennifer Muehlenkamp and others have noted that the long-term results are mixed and inconclusive.

Other empirically based treatment approaches focusing on the behavior of SI include behavioral management strategies, functional assessment analysis of SI and means restriction/delay of SI. Klonsky, Muehlenkamp, Stephen Lewis and Barent Walsh provide a nice overview of these interventions in their book Nonsuicidal Self-Injury, which is part of the Advances in Psychotherapy Evidence-Based Practice series. All of these interventions promote the use of learning new behaviors in an effort to reduce the occurrence of SI.

Pioneered by William Miller and Stephen Rollnick, and applied to the treatment of SI by Victoria Kress and Rachel Hoffman, motivational interviewing (MI) is a humanistic-based therapy that can be used to enhance client motivation to change. At its core, MI is a client-centered approach that demands counselor nonjudgment and acknowledges that every client who comes to counseling is at a different place of readiness for change. Although the application of MI to the treatment of SI has not been researched well, counselors may find MI particularly useful for fostering a strong therapeutic alliance and working with clients who may not be willing or ready to cease self-injuring.

Family interventions: Family support can be a protective factor against SI and suicide. As such, family therapy can promote client change and well-being. Family members who engage in therapy can learn how to communicate with their loved ones in ways that are affirming and nonblaming. Counselors can help educate family members on the reasons that their loved ones engage in SI behaviors.

Family therapy can also help counselors explore family dynamics and how those patterns may have influenced clients’ propensity to self-injure. Trauma, abuse, unhealthy communication patterns, inappropriate alliances and other family dynamics can occur in the family of origin and create toxic relationships that are dysfunctional and in need of repair. Counselors can help clients mend these broken relationships, which in turn can potentially decrease the clients’ desire to self-injure. Klonsky and his co-authors provide a brief overview of the support for applying family therapy to the treatment of SI in their book.

Summary

To help ensure a growth-promoting experience and minimize both risk and liability, counselors should keep a number of things in mind when working with clients who self-injure. These include the following:

  • Monitoring one’s own values when working with clients who self-injure for the purpose of avoiding making the client feel unsafe or creating inappropriate therapeutic conditions
  • Identifying when and how to make disclosures of confidential information regarding SI
  • Identifying foreseeable harm regarding severe SI or suicide
  • Using reliable and valid assessment instruments to identify and monitor SI
  • Monitoring one’s own competence to treat SI
  • Using evidence-based therapeutic interventions

Above all else, we hope readers will remember five key points about SI from this article:

1) SI is often used as a coping skill, but it always has a function (and sometimes multiple functions). For most people, that function is emotion regulation. Therefore, identifying the function or functions can help to guide intervention.

2) Treatment that focuses exclusively on stopping the SI behavior fails to address the underlying reasons for the behavior and is not likely to produce long-term change.

3) Counselors’ reactions — both verbal and nonverbal — communicate clear messages to clients who self-injure. If counselors want their clients to feel safe and not judged, counselors should start by identifying their biases regarding SI.

4) Counselors need to be specially educated and trained in how to intervene with clients who self-injure. There are risks and therapeutic pitfalls that can be minimized with adequate understanding of SI.

5) SI and suicide are not equivalent, but counselors should work to monitor suicide risk without assuming that all clients who self-injure are suicidal.

The information provided in this article is not exhaustive, but we hope readers will be stimulated to continue learning about SI so that when (not if) a client presents with SI, they will feel better able to intervene.

 

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We would like to extend a heartfelt thanks to our friends and colleagues Victoria Kress and Chelsea Zoldan for their contributions to this article.

 

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

Julia L. Whisenhunt is an assistant professor of counselor education and college student affairs at the University of West Georgia. She is an editorial board member for the Journal of Counselor Leadership & Advocacy and serves Chi Sigma Iota (CSI) International through committee membership. A licensed professional counselor (LPC), national certified counselor (NCC) and certified professional clinical supervisor (CPCS) in Georgia, she specializes in the areas of self-injury, suicide prevention and creative counseling. Contact her at jwhisenh@westga.edu.

Nicole Stargell is an assistant professor in the Department of Educational Leadership and Counseling at the University of North Carolina at Pembroke. She is a member of the CSI International Counselor Community Engagement Committee, the ACA Practice Briefs advisory group and the editorial board for the Counseling Outcome Research & Evaluation journal. She is an LPC, NCC and licensed school counselor.

Caroline Perjessy is an assistant professor of counselor education and college student affairs at the University of West Georgia.  An editorial board member of the Association for Specialists in Group Work, she has presented and published on dialectical behavior therapy and postmodern approaches to counselor practice and pedagogy. She is an LPC and CPCS in Georgia.

Letters to the editor: ct@counseling.org

 

 

Polyvagal theory in practice

By Dee Wagner June 27, 2016

Picturing brain chemistry can be something like picturing a hurricane. Although we can imagine bad weather, it is difficult to imagine changing that weather. But Stephen Porges’ polyvagal theory gives counselors a useful picture of the nervous system that can guide us in our efforts Branding-Images_chemistryto help clients.

Porges’ polyvagal theory developed out of his experiments with the vagus nerve. The vagus nerve serves the parasympathetic nervous system, which is the calming aspect of our nervous system mechanics. The parasympathetic part of the autonomic nervous system balances the sympathetic active part, but in much more nuanced ways than we understood before polyvagal theory.

Our three-part nervous system

Before polyvagal theory, our nervous system was pictured as a two-part antagonistic system, with more activation signaling less calming and more calming signaling less activation. Polyvagal theory identifies a third type of nervous system response that Porges calls the social engagement system, a playful mixture of activation and calming that operates out of unique nerve influence.

The social engagement system helps us navigate relationships. Helping our clients shift into use of their social engagement system allows them to become more flexible in their coping styles.

The two other parts of our nervous system function to help us manage life-threatening situations. Most counselors are already familiar with the two defense mechanisms triggered by these two parts of the nervous system: sympathetic fight-or-flight and parasympathetic shutdown, sometimes called freeze-or-faint. Use of our social engagement system, on the other hand, requires a sense of safety.

Polyvagal theory helps us understand that both branches of the vagus nerve calm the body, but they do so in different ways. Shutdown, or freeze-or-faint, occurs through the dorsal branch of the vagus nerve. This reaction can feel like the fatigued muscles and lightheadedness of a bad flu. When the dorsal vagal nerve shuts down the body, it can move us into immobility or dissociation. In addition to affecting the heart and lungs, the dorsal branch affects body functioning below the diaphragm and is involved in digestive issues.

The ventral branch of the vagal nerve affects body functioning above the diaphragm. This is the branch that serves the social engagement system. The ventral vagal nerve dampens the body’s regularly active state. Picture controlling a horse as you ride it back to the stable. You would continue to pull back on and release the reins in nuanced ways to ensure that the horse maintains an appropriate speed. Likewise, the ventral vagal nerve allows activation in a nuanced way, thus offering a different quality than sympathetic activation.

Ventral vagal release into activity takes milliseconds, whereas sympathetic activation takes seconds and involves various chemical reactions that are akin to losing the horse’s reins. In addition, once the fight-or-flight chemical reactions have begun, it can take our bodies 10–20 minutes to return to our pre-fight/pre-flight state. Ventral vagal release into activity does not involve these sorts of chemical reactions. Therefore, we can make quicker adjustments between activation and calming, similar to what we can do when we use the reins to control the horse.

If you go to a dog park, you will see certain dogs that are afraid. They exhibit fight-or-flight behaviors. Other dogs will signal a wish to play. This signaling often takes the form that we humans hijacked for the downward-facing-dog pose in yoga. When a dog gives this signal, it cues a level of arousal that can be intense. However, this playful energy has a very different spirit than the intensity of fight-or-flight behaviors. This playful spirit characterizes the social engagement system. When we experience our environment as safe, we operate from our social engagement system.

Trauma’s effect on nervous system response

If we have unresolved trauma in our past, we may live in a version of perpetual fight-or-flight. We may be able to channel this fight-or-flight anxiety into activities such as cleaning the house, raking the leaves or working out at the gym, but these activities will have a different feel than they would if they were done with social engagement biology (think “Whistle While You Work”).

For some trauma survivors, no activity successfully channels their fight-or-flight sensations. As a result, they feel trapped and their bodies shut down. These clients may live in a version of perpetual shutdown.

Peter Levine, a longtime friend and colleague of Porges, has studied the shutdown response through animal observations and bodywork with clients. In Waking the Tiger: Healing Trauma, he explains that emerging from shutdown requires a shudder or shake to discharge suspended fight-or-flight energy. In a life-threatening situation, if we have shutdown and an opportunity for active survival presents itself, we can wake ourselves up. As counselors, we might recognize this shift from shutdown to fight-or-flight in a client’s move from depression into anxiety.

But how can we help our clients move into their social engagement biology? If clients live in a more dissociative, depressed, shutdown manner, we must help them shift temporarily into fight-or-flight. As clients experience fight-or-flight intensity, we must then help them find a sense of safety. When they can sense that they are safe, they can shift into their social engagement system.

The body-awareness techniques that are part of cognitive behavior therapy (CBT) and dialectical behavior therapy (DBT) can help clients move out of dissociative, shutdown responses by encouraging them to become more embodied. When clients are more present in their bodies and better able to attend to momentary muscular tension, they can wake up from a shutdown response. As clients activate out of shutdown and shift toward fight-or-flight sensations, the thought-restructuring techniques that are also part of CBT and DBT can teach clients to evaluate their safety more accurately. Reflective listening techniques can help clients feel a connection with their counselors. This makes it possible for these clients to feel safe enough to shift into social engagement biology.

Specific aspects of ventral vagal nerve functioning

Porges chose the name social engagement system because the ventral vagal nerve affects the middle ear, which filters out background noises to make it easier to hear the human voice. It also affects facial muscles and thus the ability to make communicative facial expressions. Finally, it affects the larynx and thus vocal tone and vocal patterning, helping humans create sounds that soothe one another.

Since publishing The Polyvagal Theory: Neurophysiological Foundations of Emotions, Attachment, Communication and Self-Regulation in 2011, Porges has studied the use of sound modulation to hierarchytrain middle-ear muscles. Clients with poor social engagement system functioning may have inner ear difficulties that make it hard for them to receive soothing from others’ voices. As counselors, we can be conscious of our vocal patterns and facial expressions and curious about the effects those aspects of our communication have on our clients.

Based on his understanding of the effects of the vagus nerve, Porges notes that extending exhales longer than inhales for a period of time activates the parasympathetic nervous system. Porges was a clarinet player in his youth and remembers the effect of the breath patterns required to play that instrument.

As a dance therapist, I am aware that extending exhales helps clients who are stuck in forms of fight-or-flight response to move into a sense of safety. For clients stuck in some form of shutdown, I have found that conscious breath work can stir the fight-or-flight response. When this occurs, the fight-or-flight energy needs to be discharged through movement for clients to find a sense of safety. For instance, these clients might need to run in place or punch a pillow. The hierarchy of defense system functioning explains these therapeutic techniques.

Respiratory sinus arrhythmia is a good index of ventral vagal functioning. This means we now have methods to study the effectiveness of body therapies and expressive arts therapies.

Polyvagal theory in my practice

What follows is an example of how I used polyvagal theory with a client who experienced medical trauma during her birth.

The client, whom I have been seeing for some time, described feeling very sleepy and acknowledged having difficulty getting to our session on this day. Her psychiatrist had prescribed her Zoloft as a way of treating anxiety stirred by the birth of her daughter’s first child. The client and I had previously normalized her anxiety as a trauma response.

During the years before coming to see me, this client had attempted suicide, which resulted in medical procedures that added to her trauma. Through our work, she has come to understand that the panic attacks she has when in contained situations are also trauma responses. She has lived much of her life in perpetual fight-or-flight response mode.

On this day, she was relieved to be less emotional, but she feared the tiredness that accompanied Zoloft’s help in calming her fight-or-flight sensations. I saw this fear of the tiredness as a fear of dorsal vagal shutdown. We discussed the possibility that this tiredness could allow her a new kind of activation. I asked if she would like to do some expressive art that would allow gentle, expressive movement. She shuddered, naming her preference for things that were less subjective.

We talked about the existence of a kind of aliveness that still feels safe. We talked about the possibility of existing in a playful place in which there is no right and wrong, only preference. We acknowledged that since her birth, she and her parents had feared that her health would fail again. This environment in which she had grown up had supported nervous system functioning designed for life-threatening situations. With the Zoloft calming her fight-or-flight activation, I suggested that perhaps she could explore some calmer, more playful kinds of subjective experiences.

“It feels like you are trying to create a different me,” she responded. I acknowledged that it might sound as if I were thinking she could be someone she wasn’t. But I explained that what I was actually suggesting was the possibility that she could be herself in a different way.

The client told me she had a new book on grandparenting that contained a chapter on play. She said she would consider reading it. At the same time, she said that she might not be able to tolerate the Zoloft and might have to get off of it. Regardless, the idea of this different, more playful way of being has been introduced to her and, for a moment or two, experienced.

Getting the picture

As counselors armed with polyvagal theory, we can picture defense mechanism hierarchy. We can recognize shifts from fight-or-flight to shutdown when clients feel trapped. We can also recognize the movement from shutdown into fight-or-flight that offers a possible shift into social engagement biology if and when the client can gain a sense of safety.

Before polyvagal theory, most counselors could probably recognize fight-or-flight and shutdown behaviors. They could probably sense a difference between defense responses designed for life-threatening situations and responses that characterize what Porges calls the social engagement system. Polyvagal theory deepens that awareness with the knowledge that playful arousal and restorative surrender have a unique nervous system influence.

Most counselors appreciate brain science but may find it difficult to picture how to use the information. Thanks to polyvagal theory’s clarification of the role of the ventral branch of the vagus nerve, we now have a map to guide us.

 

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Dee Wagner has worked as a licensed professional counselor and board-certified dance therapist at The Link Counseling Center in Atlanta for 22 years.
Her book/workbook Naked Online: A DoZen Ways to Grow From Internet Dating helps clients use their online dating experiences to shift from attachment trauma to social engagement system functioning. Contact her at mdeewag@gmail.com.

Letters to the editor: ct@counseling.org