Tag Archives: trauma

Hearing voices: A human rights movement and developmental approach to voice hearing

By Laren Corrin March 12, 2020

In 2016, shortly after I entered a CACREP-accredited graduate program for clinical mental health counseling, I began hearing, outside of the class setting, about an international human rights movement centered around the “voice hearing” experience — what would be called auditory-verbal hallucinations in clinical mental health settings. The movement includes people with unusual perceptions that often get labeled as psychosis.

I slowly came to learn about the movement through an introductory workshop, a three-day group facilitator training, attendance in online and in-person groups for a year, and the reading of the literature on the topic. Most recently, I traveled to Montreal for the 11th World Hearing Voices Congress, where I was able to shake hands with and hear one of the movement founders, Dutch psychiatrist Marius Romme, speak.

With this article, I hope to familiarize counselors with the Hearing Voices Movement and related international networks of recovery groups. I believe the Hearing Voices Movement is in alignment with the values and ethical principles of the American Counseling Association.

History and current development of the movement

The Hearing Voices Movement started in the 1980s in Europe when a patient confronted Romme about the limitations of the psychiatric care being provided. Why, the patient asked, was it OK for Romme to believe in a God whom he could not see or hear but not OK for her, the patient, to believe in voices that she really did hear? To learn more about the voice-hearing experience and to try to help his patient, Romme had the woman’s story told on TV and asked for other voice hearers to contact him. Approximately 550 reached out.

Remarkably, many of the people who heard voices did not need clinical help. Writing in the Journal of Mental Health in 2011 after conducting a literature review, Vanessa Beavan, John Read and Claire Cartwright asserted that it was safe to say that 1 in 10 people in the general population will hear voices. Romme eventually compared psychiatric treatment to eliminate voice hearing to conversion therapy for sexual orientation.

How did he come to that conclusion? By accepting the reality of the voices rather than just checking them off as a symptom to be treated, Romme said, he could learn much more about their origin and meaning and identify ways to help his patients. He discovered that voices were often a reaction to problems in life, such as bullying or abuse, with which the person could not cope. In other words, there was a relationship between the voices and the person’s life story.

The Hearing Voices Networks (HVN) are the network of community groups that emerged from the Hearing Voices Movement. As of early March, the Hearing Voices Network USA had 119 groups listed on its national website. At the World Hearing Voices Congress that I attended, it was reported that Brazil has quickly grown over the past few years to have 35 groups, whereas the province of Quebec in Canada started with one group in 2007 and now also has 35 groups. The majority of groups are in Europe, where the Hearing Voices Movement started.

The groups developed when people with experiences of voice hearing got tired of not being listened to and of being labeled as having mental disorders. They were also frustrated by the coercive nature of the often ineffective treatments. Individuals with experiences that might be labeled as psychosis in clinical settings can meet in these groups and explore their experiences in spaces that are free of clinical judgment. If a clinician brings a person to attend a Hearing Voices group, the clinician will often be asked to wait outside or in another room while the voice hearer attends. Members of these networks believe in the freedom of voice hearers to interpret their experiences in any way they see fit. The key to this approach is for individuals to be listened to in a curious, nonjudgmental way as they describe their experiences.

People are discovering that when listened to in this way, profound healing can occur. Eleanor Longden’s TED Talk, titled “The voices in my head,” is a great introduction to this approach. Longden describes how changing her perspective on hearing voices — from a disorder to be treated to experiences with meaning if one could just open up their metaphorical wrapping — led to a huge developmental shift that allowed her to make peace with her experience.

Treatment alternatives

I firmly believe the Hearing Voices Movement is in alignment with ACA values. ACA has a rich tradition of promoting social justice, honoring diversity, and supporting the worth, dignity, potential and uniqueness of people. In clinical practice, counselors work to promote the ethical principle of client autonomy, fostering the right of clients to control the direction of their treatment and lives. This aspiration is realized with all range of mental health concerns, but experiences that could be labeled psychosis are generally approached differently in the U.S. mental health system, potentially indicating a blind spot in the field of mental health.

In contrast to the ACA values I learned in my first semester of graduate school, I began to have a growing concern when learning about counselor roles that stood in opposition to those values. Specifically related to psychosis were the two roles of providing psychoeducation and monitoring adherence to medications. This involves instructing the client in the medical model, explaining that hearing voices and other unusual experiences are symptoms of a brain disease process, asserting that symptoms have no personal value or meaning to be explored, and teaching that treatment should consist of attempting to arrest that disease process. In taking that approach, psychoeducation essentially serves to impose a particular value or framework on the client’s experience of hearing voices.

The American Psychiatric Association established the medical model upon its founding in 1844, writing in its journal at the time that “we consider insanity a chronic disease of the brain …” That is the lens and approach that the organization has taken and buttressed with evidence. Of course, the medical model framework is useful for some people, and many useful treatments have been derived from it. However, there are other people who prefer alternative social or developmental models and lenses that are more in alignment with ACA values.

A 2017 United Nations Human Rights Council report concluded that one of the barriers to mental health and wellness was a lack of free and informed consent. Specifically, “In order for consent to be valid, it should be given voluntarily and on the basis of complete information on the nature, consequences, benefits and risks of the treatment, on any harm associated with it, and on the availability of alternatives.”

The availability and awareness of alternatives and complementary approaches may be a key piece that needs some work. It is important for counselors to identify innovative approaches in line with the ACA ethical principles of client autonomy and nonmaleficence, or avoiding actions that cause harm. I believe the Hearing Voices Movement is one such promising innovative approach, with evidence building in academic journals and books, including Living With Voices: 50 Stories of Recovery, by Romme and colleagues (2009).

A developmental model

In contrast to the medical model, counselors rely heavily on a developmental model of client concerns. The Hearing Voices Movement comes very much from a developmental perspective and fully acknowledges that voices are often a reaction to problems in life. Having learned that with 70% of adults the onset of voices was related to trauma or conflicts, Romme and colleagues studied 80 children who heard voices and published the results in 2004 in the International Journal of Social Welfare. They found that 75% of children had an onset of voices in relation to circumstances they felt powerless over.

Although the Hearing Voices Movement acknowledges a trauma connection to the onset of hearing voices for the majority of people, a blanket causal explanation for all voice hearing is not declared. All explanations are given space to be heard in the Hearing Voices Networks groups, including the medical model, psychological models such as voices being subpersonalities of the voice hearer, spiritual beliefs that the voices are spirits, and other possibilities.

As a side note to the developmental perspective of hearing voices, there is a new culture emerging of tulpamancers — people who intentionally work to develop voices they call “tulpas” to interact with as friends, based on an ancient Buddhist practice. A researcher at McGill University, Samuel Veissière, has done phenomenological research on tulpamancers, and Tanya Luhrmann of Stanford University is working on a neuroimaging study of these individuals.

The book Living With Voices outlines a three-phase developmental recovery framework identified from people who recovered from the distress of hearing voices:

1) Startled phase: Anxiety and a feeling of being overwhelmed dominate. Sigmund Freud wrote about his experience of being a voice hearer while living alone in a strange city in The Psychopathology of Everyday Life. His description of his experience was translated into English as the voice suddenly pronouncing his name.

2) Organization phase: Interest in the experience is developed, and the voice hearer looks for more information.

3) Stabilization phase: Person recovers their own potential and capacity to live the life they choose.

Although this may appear to be a linear process, in actuality the process may be repeated each time that a new voice makes itself know to the voice hearer.

To clarify, in the Hearing Voices Movement, to “recover” does not mean that symptoms have been eliminated but rather that the person has recovered from the distress of hearing voices. As was the case in the not-too-distant past when homosexuality was termed a mental disorder, the solution is not to force people to be different than they are but rather to change society to allow people to accept themselves as they experience life and love. 

A role for the counselor

In the U.S. mental health system, clients who hear voices are most commonly acculturated into the perspective that their voices reflect a disease process with no inherent meaning. Frequently, once a mental health professional identifies voice hearing as a symptom, the voice hearer’s underlying traumas are systematically ignored and invalidated. The only history then asked about is family history of mental illness to confirm the diagnosis, even though the person’s trauma history could be addressed in counseling.

The Hearing Voices Movement allows many voice hearers to discover relationships between their voices and their life experiences. Some voices have the tone or use the language of a childhood bully or an abuser. Often, voices express difficult emotions that the voice hearers are not able to express themselves.

The Maastricht interview, named for the Netherlands university city in which it was created, was originally a research tool designed in collaboration with voice hearers to learn more about their experiences, but it was found to have clinical value in the beginning process for clients to explore their experiences. The Maastricht interview can be considered a voice-mapping process in which the interviewer asks the voice hearer questions about the voices. Through this process, voices are discovered to serve different purposes, such as representing unfelt emotion, protecting the voice hearer, or attempting to solve loneliness or social isolation.

Among the questions the Maastricht interview uses to accomplish this are:

  • Have you noticed whether the voices are present when you feel certain emotions?
  • Are you able to carry on a dialogue with the voices or communicate with them in any way?
  • Does the manner or tone of the voices remind you of someone you know or used to know?
  • Can you describe the circumstances when you first heard them (each voice)?
  • Please describe your own interpretation of what causes your experience and what your theory is for why you have this experience.

The Maastricht interview can be found on Intervoice, the International Hearing Voices Network website.

The Maastricht interview features eight specific questions that explore potential trauma experienced in childhood at home, in school or in the neighborhood. In addition to the counselor facilitating the organization phase of recovery for the client, these questions provide validation of the client’s life experience and raise awareness of unprocessed trauma that may be worked through more effectively with counseling than in the Hearing Voices groups.

Similarities with internal family systems

In Richard Schwartz’s internal family systems (IFS) model, a person is conceived as being born with several distinct parts (like subpersonalities), each of which can pick up burdens or traumas in life, and a core self that is not affected by traumas. The parts interact within the person, much in the way that different members of a family interact as a system.

I asked Schwartz if the IFS model could work with people who hear voices. He told me that it could. The voices can be worked with as parts in the IFS model, and Schwartz has done work with people with schizophrenia diagnoses.

In the Hearing Voices Movement, voices are seen as being very interactive within the individual who hears them. Likewise, in the IFS model, voices can be looked at as parts that interact as a family system. Additionally, in the Hearing Voices Movement, the goal is not to eliminate the voices (although that sometimes happens). Similarly, in IFS, the goal is not to eliminate the person’s distinct parts but rather to help the person discover and release unprocessed trauma burdens so that the system can live in a harmonized way. Much like in the Hearing Voices Movement, in which voices are acknowledged as real, IFS is best carried out from the understanding that a person’s distinct parts are real and can act within the internal family system.

In one last similarity of note, at the World Hearing Voices Congress, Romme said that most voice hearers know the age of their voices. At his workshop, Schwartz had some participants check in with their parts and find out what their ages were. 

Conclusion

Romme has drawn comparisons between using treatment to try to eliminate a person’s voice hearing with using treatment to try to change a person’s sexual preference. I was struck when I first read this comparison because I at the same time kept reading about ACA’s push to support bans on conversion therapy for sexual preference. Romme repeated this comparison at the World Hearing Voices Congress.

Initially, I kept thinking about the level of distress people must feel who hear voices that tell them to harm themselves or others. But I have since met, talked with and listened to so many people who hear voices — and who have really taken control of their lives by changing their relationship to those voices — that I am beginning to think that Romme is right. In my lifetime, homosexuality was included as a diagnosable mental disorder in the Diagnostic and Statistical Manual of Mental Disorders. It took a rights movement to change that. The Hearing Voices Movement — a human rights and social justice movement — is now well underway, with networks in 37 countries and counting.

 

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Laren Corrin is a counseling graduate student at the University of Southern Maine. Laren is an advocate for alternative frameworks for psychosis and complementary approaches to wellness. Contact Laren at larencorrin.com.

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

Helping clients grow from loss

By Sherry Cormier February 4, 2020

Loss is a universal experience and an underpinning of many therapeutic issues. The client who has just lost a job, the parents whose son is addicted to opioids, the client whose long-term relationship unraveled, and the client who received a devastating health diagnosis all have loss in common.

As a professional counselor and bereavement trauma specialist, I am sensitized to the ways that loss informs clients’ worldviews and emotional struggles. And as a grief survivor, I am aware of the unique ways in which loss can serve as a catalyst for growth. An African proverb captures this sentiment when it says, “Smooth seas do not make for skillful sailors.” But this raises questions: Is growth possible for everyone, and how do counselors help clients grow after a traumatic loss?

Posttraumatic growth: What is it?

Posttraumatic growth (PTG) is an approach that informs our practice as professional counselors. Richard Tedeschi and Lawrence Calhoun, who pioneered much of the research and theory on PTG, define it as positive change that follows the struggle after some kind of traumatic event. PTG represents change that occurs after a life crisis rather than during it. It usually involves longer-term change that occurs over an extended period of months to years as individuals cope with crisis by developing ways of thinking, feeling and behaving that are different from what they relied on prior to the life-changing event.

PTG is not the same as personal development or maturity. It may be thought of as something that occurs somewhat spontaneously as the result of trying to cope with a challenging life experience of seismic impact. Evidence of PTG does not imply that the loss or traumatic event was somehow desired.

Approximately 10% of loss survivors stay mired in grief, guilt and despair for an extended period of time following their loss. Clients who experience these emotions, coupled with an intense yearning for who or what was lost, might be suffering from complicated grief, which requires a particular kind of professional treatment (see complicatedgrief.columbia.edu). The majority of loss survivors do not get stuck in acute grief, however, and report some measure of growth during recovery from loss. For many of these survivors, growth may coexist with distress.

Research summary: What do we know?

In 1996, Tedeschi and Calhoun’s research resulted in the Posttraumatic Growth Inventory, a 21-item self-report measure that yielded five empirically derived markers of PTG:

1) Improved relationships with others

2) Greater appreciation for life

3) New possibilities for one’s life

4) Greater awareness of personal strengths

5) Changes in spirituality

These five markers of growth have been reported by a variety of survivors, including prisoners of war, veterans with posttraumatic stress disorder, people diagnosed with cancer or other life-threatening illnesses, people who became paralyzed from accidents, and those who have lost spouses or life partners. Although much of the research has been conducted with people living in the United States, other studies have explored PTG with individuals in other countries.

Among current findings on PTG, Tedeschi and his co-authors cited the following in their 2018 book Posttraumatic Growth: Theory, Research, and Applications:

  • About 30% to 60% of survivors report some experience of PTG following a difficult life event.
  • PTG is both a process and an outcome.
  • PTG is generally a stable phenomenon over time.
  • PTG is more evident in those individuals who score higher on measures of extraversion and openness to experience and is also related to optimism.
  • There are both universal aspects and culturally specific characteristics of PTG.

Critics of PTG point out that self-reported or perceived growth is not necessarily the same as actual growth. Some of the conflicting findings on PTG seem to be the result of differences in how growth is defined and measured across studies.

Growth-promoting practices with loss survivors

There has been less research about specific interventions and techniques that might facilitate PTG in survivors, although a predominant feature of a growth-oriented therapeutic approach involves working with client stories or narratives. The following practical strategies can be used to help facilitate growth with loss survivors.

Create a safe therapeutic environment. Traumatic loss erodes a sense of security and thrusts survivors into the middle of unfamiliar circumstances. Social support is crucial, yet many people in survivors’ social networks may be uncomfortable with grief or may offer well-intentioned comments that feel offensive to the survivor. Counselors’ first task is to provide a safe container that is comforting and companionable for loss survivors. Creating a therapeutic environment in which we listen closely and hold up a mirror to reflect these clients’ experiences will help loss survivors feel known.

Use self-care practices. Traumatic loss may disrupt the rhythm of survivors’ connections. One way to help loss survivors reestablish bonds with others is to encourage them to grow a new relationship with themselves. We can help clients do this by recommending effective self-care practices such as movement and exercise, adequate sleep, and the intake of nourishing food. In the 2012 book The Emotional Life of Your Brain, Richard Davidson points out that a lack of consistent self-care practices sabotages our ability to regulate our bodies and emotions. Mindfulness and self-compassion are additional self-care practices that can be used by loss survivors who feel emotionally flooded with anger, guilt or anxiety. Teaching self-compassion and mindful meditation to these clients can help them reestablish a connection with themselves and, ultimately, with others. These tools also enhance clients’ equilibrium, making further work toward growth possible.

Explore client narratives. An important part of therapy with loss survivors involves exploring their narratives or stories. PTG occurs most often with clients who create an adaptive narrative in which they are able to see themselves as survivors rather than victims. The following items play integral roles in exploring client narratives.

Timelines: Initially, clients can construct a timeline of their lives with significant events marked at various ages. Timelines provide critical clues about pre- and post-loss stressors as well as the loss event itself. Clients who have been subjected to many pre-loss stressors often have more difficulty discovering growth. Using strength-oriented queries when asking clients to review their timelines is useful. For example, “Juanita, I noticed you had a miscarriage when you were 20. How did you cope with that? What tools did you find that helped you through that loss?”

Clues of growth: Many clients are so affixed to the trauma of the event that it’s hard for them to detect anything positive about their story. Counselors can be most helpful by noting clues of growth and healing in clients.

For example, James, an African American in his mid-20s, is discouraged because he has been through multiple losses. The house he once lived in with his grandmother was recently obliterated by a tornado, and now she is in the hospital with multiple injuries. In addition, the business he started just folded. In recounting his narrative, James mentions that a local church has offered to help rebuild the home, and a nearby car dealership just offered him a job. He says having others reach out to him with offers of assistance feels so unfamiliar that it’s starting to change his opinions about the world and other people. Although he doesn’t identify this as an indicator of growth, his counselor does by pointing out ways in which James’ views of himself, other people and the world are shifting in a new direction.

Cultural context: Exploring client narratives within a cultural context is also crucial. Some clients may present narratives of cultural losses rather than individual losses in instances in which they have faced significant discrimination based on their race, ethnicity, gender, age, ability status or sexual orientation. It is important for counselors to be aware of the ways that clients’ cultural affiliations affect their lives and their views of traumatic loss and healing.

For example, James reveals that he has been working odd jobs since he was 14 to support himself and his grandmother, whose only source of income is a small Social Security check. James confides that this elevated level of financial stress and the recent losses he has experienced make him feel more vulnerable as a black man living in a predominantly white rural community.

Journaling: Counselors can also facilitate client narratives by encouraging the use of journaling as an adjunctive therapeutic intervention. Therapeutic journaling is a tool developed by James Pennebaker, who says that writing about traumatic events reduces stress and strengthens immune cells. Consistent journaling is most effective, but 15 to 30 minutes of journaling several days a week can be more productive than daily journaling, which may produce more rumination than growth, according to Pennebaker. When working with survivors of loss, counselors typically instruct these clients to write about their deepest thoughts and feelings regarding their loss.

Case example: Sharon

Sharon is a 62-year-old woman whose live-in partner of 40 years died of a sudden heart attack. Sharon resides in rural Appalachia, where she had lived with her now-deceased partner for many years. She has no children, and her one brother lives hundreds of miles away. Sharon stopped working in a dental office seven years ago to help take of her partner, who had uncontrolled diabetes. She has no real friends and reports that she has rarely been out of the house in the past seven years. She says that she has no neighborhood acquaintances or memberships in any social groups.

In the first several counseling sessions, Sharon sobs and indicates that she has no idea how she will go on after losing her partner. She has limited income but no real expenses other than rent and utilities. She insists that she does not want to return to work and has sufficient income to meet her monthly obligations. She presents herself as something of a loner and describes herself as isolated.

Sharon came to the community counseling center at the urging of her brother, but she is unsure that grief counseling can be helpful to her. Short of bringing her partner back to life, she doesn’t know how talking and crying about her loss will accomplish anything. She is not having trouble sleeping but feels compelled to get out of the house during the day. She drives around randomly and visits local discount stores just to have someplace to go.

Sharon becomes more interested in counseling when a grief support group is offered, and she attends several sessions. She returns to individual counseling in a much more animated state and is even able to laugh. Having made several friends in the grief support group, Sharon reports that the group has helped her feel less alone. She is able to construct a grief timeline in counseling and is amenable to doing occasional journaling when she has bursts of grief. Over time, she pursues recommendations for joining a local gym and a book club at the public library.

Four months into individual counseling, Sharon becomes interested in volunteering at a local animal shelter and starts doing so on a weekly basis. Several months later, she feels like a different person. She says she is ready to stop coming to individual counseling sessions but will continue attending the grief support group.

Not all grief survivors experience the kind of growth that Sharon experienced — or so quickly. Even though she continued to miss her partner terribly, her life as a caregiver for the past seven years had precluded her from developing much life satisfaction for herself. Her ability to make friends and develop social connections and her volunteering activities with the animal shelter gave her a great deal of self-efficacy and provided positive ways to deal with the absence of her partner.

Some people will not cope with loss as effectively as Sharon did. Those who experience losses associated with violence or who have coexisting diagnoses such as depression, anxiety or substance disorders are more likely to go through an extended recovery period for healing. In addition, many grief survivors feel guilty for experiencing any kind of satisfaction, as if it amounts to some kind of betrayal of the person who is no longer here.

At the same time, it is not uncommon for grief survivors to reevaluate and shift their priorities in life, in part because their life circumstances have changed. For example, Emilee lost her spouse Roberto, who was a retired military officer and active in veterans’ affairs. Roberto had spent his retirement years traveling internationally in support of this cause. Emilee had rarely accompanied him because of her fears of terrorism and plane crashes. After Roberto’s death, however, Emilee decided to engage with the same veterans’ foundation that Roberto had been active in and found herself traveling all over the globe. Emilee wanted to preserve her spouse’s legacy and share her own gifts with a larger number of people. Loss survivors such as Emilee and Sharon who find ways to give back or volunteer are more likely to report narratives of growth.

Being attuned to growth

Potential for growth exists when clients uncover meaning from their loss and construct narratives that fit into their worldview and sense of self. Skilled counselors can serve as guides to help survivors make sense of what has happened. No survivor should ever be pushed to grow, but having a counselor attuned to growth may be the missing piece that helps clients become more resilient in the face of traumatic loss.

In my own experience as a grief survivor following a series of personally devastating losses, awareness of my growth sneaked up on me. It was as if a dimmer switch got turned up again as my outlook and mood shifted in a positive direction. I include this because being attuned to indices of growth may be one of the best ways that we can help clients recognize growth possibilities and emerge from the darkness of a traumatic loss to find light again. As Jon Kabat-Zinn, founder of mindfulness-based stress reduction, has said, “You can’t stop the waves, but you can learn to surf.”

 

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Sherry Cormier is a licensed therapist, certified bereavement trauma specialist, and former faculty member at the University of Tennessee and West Virginia University, as well as being a public speaker, trainer and consultant. She is the author of Counseling Strategies and Interventions for Professional Helpers (ninth edition), senior author of Interviewing and Change Strategies for Helpers (eighth edition), and co-producer (with Cynthia J. Osborn) of more than 100 training videos for Cengage. Her newest book is Sweet Sorrow: Finding Enduring Wholeness After Loss and Grief. Contact her through her website, sherrycormierauthor.com.

 

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

 

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

One in three American kids affected by adverse childhood experiences

By Bethany Bray November 5, 2019

One-third of American children have gone through a negative experience that can have lasting implications for their physical and mental health, according to the U.S. Health Resources and Services Administration (HRSA).

Data from the agency’s most recent National Survey of Children’s Health indicates that 33% of children ages 17 and younger have gone through an adverse childhood experience (ACE) such as domestic violence or parental incarceration. Approximately 14% of children have gone through two or more ACEs, with a higher prevalence among black youths and those who live in households that are below the federal poverty level.

Among the children who took the 2018 survey, the most prevalent ACE was the divorce or separation of a parent/guardian (23.4%), followed by living in a household with someone with a drug or alcohol problem (8%), and the incarceration of a parent/guardian (7.4%).

“The new HRSA data is important because it helps us remember that all children are vulnerable to adverse experiences,” says Evette Horton, a licensed professional counselor supervisor and president of the Association for Child and Adolescent Counseling, a division of the American Counseling Association. “Our job as counselors is to assess for these adverse experiences and enhance the resilience factors that we know support children and adolescents. These include evidence-based mental health treatments, strengthening family support systems, and connecting to other resources in the community. Professional child and adolescent counselors are well-versed in promoting protective factors and stand ready to support children with any adverse experience.”

The U.S. Centers for Disease Control and Prevention defines ACEs as “all types of abuse, neglect and other potentially traumatic experiences that occur to people under the age of 18.” These experiences can range from the death of a parent to emotional or physical neglect and witnessing violence in a home or neighborhood.

Research has connected ACEs to health problems later in life such as mental illness, heart disease, addictive disorders, cancers and diabetes, and risky behaviors such as illegal drug use, unintended pregnancy and suicide attempts.

HRSA collects information on a range of children’s health-related topics from households across the U.S. for its annual survey; the most recent survey includes data from more than 30,500 children.

HRSA cannot directly compare the 2018 rate of ACEs to data from previous surveys because the language in a question asking about ACEs was changed last year. However, when excluding data for the question that was altered (regarding financial hardship), there was not a significant change in the number of ACEs between the 2016, 2017 and 2018 surveys.

 

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More from HRSA on the National Survey of Children’s Health: hrsa.gov/about/news/press-releases/hrsa-data-national-survey-children-health

 

Fact sheet on the 2018 survey: mchb.hrsa.gov/sites/default/files/mchb/Data/NSCH/NSCH-2018-factsheet.pdf

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Related reading, from Counseling Today:

Coming to grips with childhood adversity

The toll of childhood trauma

Informed by trauma

Counseling babies

Standing in the shadow of addiction

What’s left unsaid” (on child sexual abuse)

Interventions for attachment and traumatic stress issues in young children

Touched by trauma

 

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Follow Counseling Today on Twitter @ACA_CTonline and on Facebook at facebook.com/CounselingToday.

 

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

 

Addressing intimate partner violence with clients

By Bethany Bray June 24, 2019

Licensed mental health counselor Ryan G. Carlson had just earned his master’s degree when he began working on a grant-funded project to provide relationship education to couples in the Orlando, Florida, area. Overseeing the intake process as local couples came into the university-based research center to participate, he quickly learned two things: Domestic violence “is very prevalent — much more prevalent than I realized — and it’s complicated,” says Carlson, an associate professor of counselor education at the University of South Carolina. “Every case was a little bit different than the next.”

The National Coalition Against Domestic Violence reports that on average, nearly 20 people per minute are physically abused by an intimate partner in the United States. On a typical day, domestic violence hotlines across the country receive more than 20,000 phone calls.

Approximately 1 in 4 adult women and 1 in 7 adult men report having experienced severe physical violence from an intimate partner in their lifetime, according to the U.S. Centers for Disease Control and Prevention. In addition, 16% of women and 7% of men have experienced sexual violence from an intimate partner.

Carlson’s experience led him to study domestic violence while earning his doctorate, and it remains a career focus for him as he conducts research, does interdisciplinary work and conducts trainings for mental health professionals. “We assume when there’s violence in a couple’s relationship, they will tell us [in counseling]. What I’ve learned is if we don’t ask the right questions, they won’t tell us, and you shouldn’t ask those questions if you’re not ready for their disclosure,” he says. “It’s really complicated and emotionally charged. … A victim’s safety should be at the center of every decision we make as counselors.”

Handle with care

Counselors who notice patterns of maladaptive behavior, self-esteem issues or what appears to be poor decision-making by clients may automatically want to roll up their sleeves and dive into goal-setting and other go-to techniques to foster change and growth. However, engaging in change-focused work when a client is experiencing IPV may be harmful, warns Taylor Cameron, a licensed professional counselor (LPC) and director of transitional housing at Denton County Friends of the Family, a nonprofit agency in Texas that provides support services to victims of domestic violence and sexual assault. It also offers an intervention program for offenders.

The tried-and-true counseling method of talking through clients’ life scenarios, behaviors and choices while asking questions such as “What could you have done differently?” or “What would you want to change if this happens again?” can be hurtful because a counselor may inadvertently be placing the responsibility for the abuse on the victim instead of on the abuser, Cameron says. She cautions that counselors must choose their language carefully to avoid making the client feel that they are somehow to blame for the abuse they have endured.

“Victims of domestic violence do many things to survive or to try to protect themselves within the relationship,” says Cameron, an American Counseling Association member. “However, the partner carrying out the abuse is solely responsible for the violence.” Ultimately, the client can’t control — and should never be made to feel that they shoulder the blame for — what their partner does, she emphasizes.

Carlson, who is also a member of ACA, agrees. He notes that it isn’t helpful for professional clinical counselors to identify client behaviors that could be changed or avoided when clients may have adopted those patterns as a means of self-protection.

“It’s important to be careful about how we phrase things with [these] clients,” says Carlson, director of the Consortium for Family Strengthening Research and coordinator of the Center for Community Counseling at the University of South Carolina. “Avoid anything that has to do with ‘what could you have done differently?’ questions, anything that would allude to how [the client] contributed to their current situation. … It’s a delicate balance, but it’s really important to avoid language that [even inadvertently suggests] a victim is somehow at fault for being in that relationship.”

“It doesn’t matter what they change about themselves because that is not going to change the other person,” says Margaret Bassett, an LPC and deputy director at the Institute on Domestic Violence & Sexual Assault at the University of Texas at Austin. Counselor practitioners must consider the entire context of a client’s behavior to fully understand why they’re making those decisions, she says. Decisions that victims of abuse make — often for reasons of safety — can appear maladaptive from outside the context of the abusive relationship.

Bassett recalls a client who talked about agreeing to meet her estranged husband at a public library. Without understanding the full context of the situation — that if she didn’t meet with him, he had a history of escalating — a counselor might assume that the client was complicit in maintaining the abusive relationship rather than appreciate her layered safety planning, Bassett says.

“It was a brilliant move. It was safe to meet there because he couldn’t escalate without drawing attention,” Bassett explains. “Not meeting him just was not possible. This was meeting on her terms versus his terms. … This ties into [a counselor] listening and really hearing what the person is saying and not judging it out of context. Really being able to say, ‘That is a brilliant idea that you had.’ It’s not a good or a bad choice. Instead say, ‘When I hear that, I hear the safety it creates.’”

Victims of abuse often adopt patterns and behaviors that are the best choices they can make in a bad situation, Bassett notes. Professional clinical counselors should listen carefully to understand the full context of clients’ lives and then validate the choices they are making to safely navigate abusive and potentially violent situations. “Respect that they’re making a decision and really understand their safety concerns so your intervention is helpful and doable,” Bassett says.

Power and control

IPV happens between partners of all cultures and backgrounds — couples who are married and unmarried, heterosexual and homosexual, wealthy and poor, religious and nonreligious, white, Asian, Hispanic, African American and every other race. In addition, IPV often intersects with sexual assault; homelessness or disruptions in housing, schoolwork or employment; financial trouble; parenting issues; and myriad other challenges that spill over into the mental health issues that commonly bring clients to counseling.

Although the terms domestic violence and intimate partner violence both include the word “violence,” the abuse doesn’t always have a physical component, or the violent behavior is combined with emotional, nonphysical manipulation. What defines a behavior or relationship as abusive is a common thread of power and control. In its simplest definition, domestic violence is an intentional pattern of behaviors used by the abuser to gain and maintain power and control over another person, Cameron explains.

“It’s important to recognize that abuse is not an anger management issue,” she says. “People who are truly experiencing an anger management issue will go off on their boss, their cousin, the random guy at 7-Eleven. Abuse is carefully targeted at one person.”

Controlling behaviors are one of the biggest red flags counselors should be listening for to determine if a client might be involved in an abusive relationship, either as a perpetrator or a victim. Examples include checking or monitoring a partner’s cell phone, email or social media, or insisting that a partner text when they arrive at and leave from work every day. Other cues for which Cameron stays alert include:

  • Clients who clam up in session or appear to be afraid of their partner
  • Clients who are isolated from friends and family
  • Clients who feel they can’t go to work, school or social engagements because it upsets their partner
  • If one partner is the sole decision-maker or in complete control of the couple’s finances
  • If one of the partners continually feels guilty for their behavior
  • A partner who exhibits extreme jealousy
  • Clients who mention “walking on eggshells” around their partners
  • Clients who are having thoughts of suicide or threatening to harm themselves or their abuser
  • A partner who pressures the other partner to use drugs or alcohol or to not use contraception (or who lies about their own use of contraceptives)
  • A partner who pressures the other partner to have sex or to perform sexual acts that the person is uncomfortable with
  • Clients who talk about a partner belittling or embarrassing them in front of other people

Control tactics often go hand in hand with perpetrators minimizing or placing blame for their behavior, Cameron adds. Perpetrators of abuse may tell a victim that they wouldn’t have to act this way if the person came home from work on time, paid the bills on time, didn’t talk back, etc. Or, Cameron says, they may tell a partner, “It could have been a lot worse. I only shoved you. I didn’t punch you.”

In counseling, perpetrators may make statements such as, “I didn’t hurt her. I just punched the wall.” The behavior implies, however, that the perpetrator could have hurt the person, Cameron points out.

“Someone who is abusive will try and deflect attention away from the abuse,” Bassett says. “They will try and name what is happening. Maybe they push or strangle or pull their partner’s hair. But they will say, ‘I am not abusive because I never hit you. Have I ever hit you?’ or [point out that] there was no bruise. There’s a lot of crazy-making behavior that goes on. They’ll deny it ever happened or focus on something else. Abuse is a pattern of behavior, and the abuser will rationalize those patterns as something else. Pay attention to that as a therapist and help them to name the behavior [for what it is].”

If a client mentions that they fight a lot with their partner or that the partner has a temper or a “short fuse,” counselors can prompt the client to explain the fights, Cameron says. For example, “Tell me what these fights look like. Are there times [when] it feels unsafe?” Victims may use phrases such as “sometimes he is rough with me” or he “put hands on me,” not fully recognizing the behavior as abuse, she notes.

Carlson also recommends that counselors use carefully worded questions to follow up on statements made by clients to further explore the nature of their relationship experience. For example, ask clients how they handle conflict with an intimate partner and then use leading questions to learn more: When there is a disagreement, is it safe to talk about the disagreement? Is there any type of pushing, shoving, hitting, use of objects, physical violence, threatening language or name calling? Is jealousy a motivating factor? Does one partner place blame on the other, making statements such as, “You made me do this”? Is the partner violent or hostile outside of the relationship?

“Ask questions that determine if there is regret or remorse [after conflict] or if they recognize that there are other ways of handling conflict,” Carlson says.

In sessions with individual clients, Carlson recommends that counselors preface some of their most direct questions — such as “Are you afraid of your partner?” — with dialogue that prepares the client. “Say, ‘I have some questions for you about how you handle conflict in your relationship. They’re going to be very direct, and I wanted to give you a heads up, but it will help me better understand what you’re going through.’ Really tap into your basic counseling skills, the relationship-building skills that we learn early on, and emphasize those when such important questions are being asked,” Carlson says.

At the same time, Bassett adds, clinical counselors shouldn’t be afraid to ask hard questions of a client when appropriate. “Ask not just, ‘Has your partner physically assaulted you?’ but ‘Are you afraid of your partner?’ and be willing to explore that. Explore the emotional piece of abuse.”

Counselors can also supplement their own questions by using a formal questionnaire — Carlson recommends Brian Jory’s Intimate Justice Scale — or including questions on intake forms. Keep in mind, however, that clients may answer “no” to questions that later turn out to be a “yes” when explored in therapy.

Perpetrators of domestic violence often use manipulation to gain and maintain control over a person and keep them in the relationship, Cameron says. When alone with a partner, perpetrators sometimes threaten suicide if the partner ever were to leave them, or they make statements inferring that the partner would be worse off on their own: “If you leave, you won’t get any money”; “You will lose the kids”; “No one will ever love you. I’m the only one who will put up with you.”

“One of the biggest power tools is fear — abusers wield fear,” Cameron says. “They use fear to control their partner. In addition, abusers will often apologize for the abuse and say, ‘It will not happen again,’ without being accountable. Then they continue using control tactics.”

This can be complicated further if the couple’s friends and family take sides or if the victim comes from a culture or faith community that emphasizes submission to a partner, views marriage as an unbreakable bond, or values reconciliation over safety, Cameron adds.

Manipulation by a perpetrator can also extend to sexual assault, which often overlaps with domestic violence, Bassett says. “It’s also common for an abusive person to force or pressure sex [with an intimate partner]. They will define the experience as nonabusive and lay the groundwork for the survivor to agree to sex so that they aren’t forced,” she says. “The abuser is [then] able to say that they agreed to sex, making them complicit in what is actually a sexual assault. The abuser defines the experience, and the survivor needs the space and safety to name their experience [in counseling].”

Hard questions, empathetic listening

Most of all, clients who are currently in or have been in an abusive relationship in the past need a safe space to feel heard and validated and to be connected to resources to address their safety, Cameron says. It’s no surprise that building a therapeutic bond is especially important with these clients.

“Communicate that you believe them,” Cameron urges. “The most restorative thing [for the client to hear is] ‘it’s not your fault, and it’s not OK that they are doing this to you.’”

“It’s incredibly important to be nonjudgmental,” agrees Carlson. “There are so many practitioners who have a personal connection to this topic, it can be an emotive experience. The time of disclosure is a very important moment for the victim and can be filled with a lot of embarrassment and shame. When they are deciding how much to disclose, it’s often based on how they feel it will be received. … It’s important to manage your emotions in that moment because it’s such an important moment.”

“You may leave the room and feel, ‘Oh my gosh, this is an emergency. I have to get this person out.’” Carlson continues. “But remember that this is their daily reality. They’ve been living with this [abuse] for a while. It feels like an emergency to you, but to act on that may put the victim in danger. It’s important that the victim drives the steps of what happens next.”

Bassett agrees: “Be very aware that your goal [as a counselor] is not that they should leave the relationship. That needs to be a goal they make themselves. They have to own it, because any decision they make will potentially have ramifications for them.”

Cameron notes that taking decisions out of the hands of clients is one of the worst mistakes counselors can make when working with victims of IPV. “They’ve already had someone control their life, and we don’t want to step into that role,” she says. “The victim has the best knowledge about what they need.”

It’s vital for practitioners to explore a client’s experience with genuine care, says Paulina Flasch, an ACA member and an assistant professor in the professional counseling program at Texas State University. “Really show concern and empathy and don’t sound like you’re interrogating them,” says Flasch, who runs a family violence research team at Texas State and worked at a domestic violence agency before and during her master’s program. “Focus on the counselor-client relationship, and ask [hard questions] because you really care. Share that what you’re hearing sounds abusive and that it must have been really hard [to go through]. … If you’re hearing that a past relationship was abusive, it’s important to call it that and identify its aftereffects. It can help validate their current experience and help them understand why they’re struggling. Help them look at patterns and how things tie together. … It’s a very powerful moment when the client connects the dots.”

“This is a person whose boundaries have been violated and who has not had safety and security — and we [counselors] have to be careful with that,” Flasch continues. “We have to let them know there will be a different response and they won’t be demeaned. If they went through that, they’re strong. Recognize that.”

All of the counselors interviewed for this article recommend using psychoeducation techniques and the Power and Control Wheel system (available at theduluthmodel.org) to talk through what a healthy relationship looks like (and does not look like) with clients who have experienced IPV. Bassett also stresses that work with IPV clients must be trauma-informed.

Emotionally focused therapy (EFT), expressive therapies, bibliotherapy or cinematherapy, grounding techniques and decision-making exercises can also help IPV clients, Flasch notes, as can attending support groups for IPV survivors in addition to counseling.

Victims of domestic violence often grapple with intense feelings of guilt or shame, sometimes made worse by harmful stereotypes and society’s general misunderstanding of the complexity of abuse. Victims can hear messages such as “Why didn’t you just leave him?” or “Why didn’t you get out sooner?” in both direct and indirect ways in popular culture, from family and friends, or in offhand remarks by acquaintances.

The reality is that it’s not that simple, Flasch notes. Victims of domestic violence are in the most danger when they are ending a relationship with their abuser (see sidebar, below). In addition, domestic violence often creeps into a relationship slowly over time in ways that are unrecognizable to the victim.

The relationship “hasn’t always been dangerous,” says Flasch, who has a private practice in Austin, Texas, and specializes in working with couples and individuals who have experienced trauma. “There have been a lot of pieces that have kept them in the relationship. If they had known this was going to happen, they would have never been in the relationship. Intimate partner violence is the breaking down of a human. They completely lose their sense of self and begin to believe everything the abuser has said about them. It happens smally and slowly.”

Pointing out this trajectory to the client emphasizes that it wasn’t their fault and helps them learn what to look for in future relationships, Flasch adds. “Normalize it with the client. This [IPV] is very common and very similar in the ways it comes to happen,” she says. “It’s a systematic breakdown of a person that happens in very small steps that no one would recognize unless you know what you’re looking for. Helping them understand what and how it happened can help take away some of that fault and blame. Then work on empowerment. Victims have had to ask their abuser for everything. It’s our job to get their voice back.”

Planting seeds

In addition to providing a safe space to be heard and empowered, counseling can be a place for victims of IPV to learn what a healthy relationship looks like. This is especially true for clients whose histories include past trauma (in addition to IPV) or who haven’t been exposed to healthy relationships in their life, Flasch notes.

“The counselor may be that first one, that first good relationship and having a feeling of being in a room with someone who cares,” she says. “Model that through your interaction with clients. Psychoeducation is a big part of working with [IPV] victims and survivors.”

Flasch suggests using the Power and Control Wheel while discussing what it feels like to be in a healthy relationship: What aspects are present? What does respect look like? How do arguments start and end? What does equality look like?

Making a list of the elements in a healthy relationship can also help, Flasch says. “It’s not tangible [to clients] sometimes. There’s so much self-blame and lack of trust of themselves and their own instincts. They often don’t trust themselves to make decisions or recognize if something [in a relationship] is dangerous.”

It can also be helpful for counselors to talk through boundary issues with IPV survivors, including what is and isn’t their responsibility in a relationship, Bassett adds.

“With someone who is abusive, that person will not accept responsibility [for abusive behavior]. The person who is being abused typically will accept full responsibility,” she says. “They may claim, ‘Oh, he’s Dr. Jekyll and Mr. Hyde. He’s so sweet, but when he drinks, or goes off his medication [he turns dangerous].’ That’s just not true: The good parts and the loving parts are part of the [control] strategy. Be very clear about that. … Help them not to buy into it, overtly or covertly.”

Couples counseling and safety

A relationship in which IPV is present has, at its core, an imbalance of power and control. This imbalance makes couples counseling an unsafe environment for the person experiencing the abuse, Carlson stresses. If a counselor is working with a couple exhibiting signs of IPV, he or she should take steps to terminate couples counseling as soon as possible while ensuring the victim’s safety, Carlson says.

“If power and control exist in the couple’s dynamic, it’s generally not safe to be in a setting [i.e., couples counseling] where they’re both on equal ground being asked to practice healthy behaviors and make changes,” he explains. “That can’t happen when there’s inequality.”

Cameron agrees. “Each session is posing a safety risk for the victim. In couples counseling, we’re asking both parties to be accountable for solving problems in the relationship, and part of the control tactics [of IPV] is making the victim feel that it’s their fault.” Perpetrators of abuse may retaliate against their partners after counseling sessions in reaction to what was said or disclosed, she says.

On the flip side, abuse victims may say only what they need to say to keep from “making waves” with their abusers during counseling sessions. In addition, “an abuser may be very charming and manipulate the counselor,” Cameron says. Counselors who don’t recognize the manipulation or other possible indicators of IPV can end up unintentionally colluding with the abuser, she points out.

Both Cameron and Carlson recommend that counselors — whether they work with couples or individuals — seek training on IPV to stay informed on best practices and forge connections with local domestic violence agencies. It is important to establish these working relationships ahead of time so that counselors can readily consult with specialists when they identify signs of IPV with a client (or a couple) on their caseload, Carlson says. “Consultation [with an IPV specialist] helps to create a methodical, well-thought-out plan for that point forward,” says Carlson, noting that any consultation must be done within ethical guidelines and without sharing any identifying details about the individuals involved.

Once a counselor has identified that IPV is present in a relationship, the steps to terminate couples counseling must be handled delicately. Counselors should never let the abuser know that they suspect abuse is taking place, Cameron emphasizes. At the same time, a fine balance must be maintained to ensure that a victim doesn’t lose contact with the counselor and is connected to resources before couples counseling is terminated.

“Never confront abuse head-on with both parties in the room. That will put the survivor at risk,” Cameron says. “Get creative for ways to get the survivor alone. … Come up with a reason to separate them and then check in with the survivor. Ask them if they feel safe at home. Just straight up asking if they are being abused — they are not going to recognize it that way. Often, the abuser has worked really hard to convince the victim that there is no abuse.”

Cameron has known counselors who separate the couple by asking one of the partners to fill out paperwork in the waiting room. Practitioners can also try to speak over the phone outside of session to clients who are suspected targets of abuse, as long as they ensure the client is alone for the call, Cameron adds.

Carlson notes that it’s not uncommon in couples counseling for a practitioner to meet with one of the clients individually to work on an issue. Counselors can fall back on that as an excuse to separate a couple when it is suspected that IPV is present, he says.

“When [you] first meet with a couple, separate them to fill out an intake questionnaire and speak with them individually. That way, you set a precedent of talking separately,” Carlson says. “Then, you can say later, ‘We are going to meet individually to follow up on some of the things we talked about’ [at intake]. There is precedence, and it doesn’t seem out of the ordinary.”

Flasch agrees and suggests that couples counselors do full individual sessions with both partners after the first two or three sessions, regardless of whether IPV is suspected. In these sessions, counselors should always assess for IPV. She suggests asking questions such as “How do you and your partner show respect for each other?” and “Tell me about your arguments: How do they start and end, and who initiates?”

A counselor’s next step should be to connect the victim with local support services. This must also be handled carefully, Cameron says. For instance, a client could put a domestic violence hotline number in their phone under another name, or the counselor could give the information verbally to the client to remember and look up later. Cameron also recommends that counselors leave pamphlets and other information about domestic violence resources in the lobbies and restrooms of their offices for all clients to see and have access to.

If appropriate, Cameron recommends that counselors also connect perpetrators with a local batterer or offender program.

“It’s important to work in collaboration with your local [domestic violence] agency,” Cameron says. “For us to address abuse in our communities, there needs to be community accountability for abusers, and that can’t just come from domestic violence agencies. It needs to come from all aspects of the community. You’re not going to end domestic violence just by dealing with the aftermath.”

Once clients are given information about IPV resources, it’s up to them to seek help when they are ready and feel safe doing so, Carlson adds. It’s not a counselor’s role to ensure the client has followed up with those resources.

“Sometimes nothing happens,” Carlson acknowledges. “You present resources and opportunities and they know they have options, and that’s the biggest step they want to take at this point in time.”

Relationships post-IPV

Dating and forming new relationships can play a part in the healing process for survivors and help them learn more about themselves, their boundaries and their limits, says Flasch, who co-authored the article “Considering and Navigating New Relationships During Recovery From Intimate Partner Violence” in the April issue of the Journal of Counseling & Development. Counselors should be aware that the risk exists for survivors of IPV to find themselves in another abusive relationship. However, forging new healthy relationships — with a counselor as a support and ally — can be a helpful step in the right direction, she notes.

“Survivors have to work through these issues for a lifetime, so waiting for the ‘right time’ to date post-healing may never come,” Flasch says. “A counselor can be a great support for a survivor. We know that most people continue to date. To say that you should be healed completely before you go out, it’s not realistic. And healthy relationships can be incredibly healing. Having a person who is safe and loving and accepting is a huge benefit. We [counselors] shouldn’t necessarily discourage dating but help them navigate the process. Educate them about red flags and warning signs, and celebrate the successes of milestones reached through dating. Also [process] triggers and things that get in the way.”

“Having experiences with other people and then processing it in counseling can be very powerful and helpful to healing,” she continues. “We can be great allies and celebrate with clients when they try something new.”

For the journal article, Flash and her co-authors studied the experiences of IPV survivors who went on to try new relationships, ranging from casual dating to marriage. Through these relationships, participants reported learning to trust themselves and their instincts and “reclaim parts of themselves lost during the IPV relationships,” Flash wrote with her co-authors, David Boote and Edward H. Robinson.

Dating post-IPV “can be a process for survivors to try and find corrective experiences and explore trust, make decisions that are theirs and be their own person, [and] learn about control and boundaries,” Flasch says. “But this is also a very scary process and one that has a lot of layers to it, so it can bring challenges. It can be hard to learn to trust when it’s been taken away from you in the past.”

 

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IPV: Need-to-know points for counselors

One of the most misunderstood aspects of intimate partner violence (IPV) is how complicated and dangerous leaving an abusive partner can be, says Taylor Cameron, a licensed professional counselor (LPC) and director of transitional housing at a Texas nonprofit that provides support services to victims of domestic violence and sexual assault. The power imbalance of abusive relationships often means that one partner has severely restricted the other’s access to finances, friends and family members, and community resources. Separating from an abuser often means starting life over, which is why there is an intersection of IPV and homelessness, she says. These factors are only exacerbated when children are involved or when the victim experiences other forms of systemic oppression such as racism, homophobia or classism.

“They are often trapped between violence and homelessness,” Cameron says. “The abuser has often messed up their credit and finances or totally controlled them, so they’re starting from scratch. The most dangerous time for a victim is during separation and when they are separated [because] the abuser is losing the power they have worked to gain and maintain.”

According to Cameron, IPV victims are at the highest risk of lethality under the following circumstances:

  • When the couple has separated or is in the process of separating
  • If sexual abuse or sexual coercion is present in the relationship
  • If an abuser makes threats of homicide or suicide
  • When a restraining order is filed
  • If the victim is pregnant
  • If strangulation is occurring
  • If violent behavior is occurring outside of the home (which indicates the abuser has escalated to the point where he or she does not care if other people see the behavior, Cameron says)
  • If there is involvement with child protective services
  • If the abuser has access to weapons
  • If the abuser exhibits stalking behaviors
  • If law enforcement is involved

Counselors should also keep in mind that even when victims leave an abusive relationship, they may still come in contact with their abusers — and be put at risk for retraumatization — through legal proceedings, child custody hearings or stalking behavior, adds Paulina Flasch, an assistant professor in the professional counseling program at Texas State University.

“Just because someone is no longer in an IPV relationship doesn’t mean they’re no longer in it. Remember that and equip them with tools [to cope],” Flasch says.

 

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Important resources

 

Margaret Bassett recommends the following books for practitioners:

  • Why Does He Do That? Inside the minds of angry and controlling men by Lundy Bancroft
  • Battered Women’s Protective Strategies: Stronger Than You Know by Sherry Hamby
  • Coercive Control: How Men Entrap women in Personal Life (Interpersonal Violence) by Evan Stark
  • Safety Planning with Battered Women: Complex lives/Difficult Choices by Jill Davies, Eleanor J. Lyon and Diane Monti-Catania
  • The Verbally Abusive Relationship by Patricia Evans
  • Domestic Violence Advocacy: Complex lives/Difficult Choices by Jill Davies and Eleanor J. Lyon

 

Related reading, from Counseling Today:

 

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Bethany Bray is a senior 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.

Interventions for attachment and traumatic stress issues in young children

By Cirecie A. West-Olatunji, Jeff D. Wolfgang and Kimberly N. Frazier April 2, 2019

Although mental health professionals acknowledge that clinical issues often look different in young children, treatment practices continue to rely heavily on adult literature. These mostly miniaturized forms of adult treatment are often scaled down using more basic language and vocabulary, but they still depend on discovering ways to encourage the verbal communication of children. Furthermore, major deficiencies exist in the mental health care delivery system for children. General neglect and fragmentation of services create obstacles to effective service provision for this population.

Over the past decade, scholars have begun exploring early childhood development and effective counseling interventions, the role of traumatic stress in the presentation of emotional and behavioral symptoms, and the prevalence of attachment issues for young children. In this article, we aim to provide a brief overview of these key advances in what we have named “pediatric counseling.” We also offer 10 evidence-based counseling interventions that stem from our work with young children over several decades.

Early childhood development and counseling

Children are not miniature adults, meaning a paradigm shift and specialized skills approach are required to help them most effectively. Children also go through rapid developmental stages, strengthening the argument that therapy with children should be vastly different from therapy with adults. Thus, professional counselors and other mental health professionals must consider various concepts, issues, techniques and interventions that are cognitively, emotionally, psychologically and developmentally appropriate for children.

During early childhood, defined as birth to age 5, rapid development of gross motor skills (running, climbing, throwing) occurs. Fine motor skills (drawing, writing, manipulating small objects) are slower to develop at this stage, but children should be able to copy letters and small words sometime during the latter half of early childhood. Cognitive development at this stage is based primarily on preoperational thinking. Hence, children in this stage rely heavily on what they see. They can now recall past events and anticipate future experiences that may be similar. At this stage of development, children are very egocentric, commonly overestimate their abilities (e.g., thinking they can carry things that are too heavy for them), and gain increased control of their impulses.

Play is extremely important to social development during early childhood. At about 3 or 4 years old, children engage in associative play in which they learn how to share and interact with one another. During associative play, there are no clear goals for the play and the roles of those engaging in play are not assigned. At about age 5, children begin to create games, form groups and take turns. Children are expanding their vocabularies at this stage, but the words and phrases used to express feelings and emotions remain limited. Because of their limited emotional vocabulary at this stage, children are more prone to act out their emotions behaviorally.

Deficiencies in service delivery:
Some of the major deficiencies in the mental health care delivery system for children include:

  • How children are categorized (i.e., poor conceptualization of children within their ecological context, including culturally marginalized children being overrepresented in the most severe clinical categories)
  • Environmental factors (such as racism and poverty)
  • Lack of empirical data
  • Fragmentation of services

First, children are typically placed in categories of clinical, subclinical and at risk, and they are often in need of services such as remediation and prevention. However, they are largely neglected within the system. This is partly due to clinicians’ lack of training to provide developmentally appropriate clinical care for this age group. Lack of adequate funding and poor communication between providers (such as pediatricians, child care workers, parents/caregivers, social services personnel and professional counselors) are also factors.

Second, some environmental factors associated with higher rates of mental health problems include poverty, racism, abuse and familial problems. Systemic oppression is also linked to both behavioral and affective problems. However, insufficient research has been conducted with young children to provide adequate information about how these environmental factors affect them. 

Third, there is a lack of empirical data on effective treatment for young children. Although the literature is replete with community agency programs and hospital-affiliated programs designed for young children and their families, there is insufficient support for the effectiveness of the treatments and interventions provided.

Finally, there is fragmentation of the services that exist for this population. Mental health services for young children should be initialized by a social service agency or primary care physician. However, this rarely happens. Even when it does, it is unlikely that these professionals have included or interacted with counselors. Thus, many children slip through the cracks and remain unidentified until a crisis arises, meaning they are most likely to receive psychological first aid via psychiatric services.

Counselor training: Experts stress the need for counselor trainees to acquire foundational skills that serve as underpinnings for effective counseling of this population. The major challenge within the discipline of counseling is how to transform these base-level skills into effective techniques and interventions for young clients. Many beginning counselors feel ill-prepared and are often frustrated when they encounter child clients — and preschool-age children in particular. Most counselors begin their training by practicing their counseling skills on classmates and never encounter younger client populations until they are out in
the field. 

Traumatic stress issues

Researchers have suggested that symptoms of traumatic stress in early childhood include interrupted attachment displays of distress such as inconsolable crying, disorientation, diminished interest, aggression, withdrawing from peers, and thoughts or feelings that disrupt normal activities. Traumatic stress, a condition caused by pervasive, systemic external forces, can result in physiological, psychological and behavioral symptoms that negatively affect everyday functioning.

Symptoms of traumatic stress can include hyperarousal or hypoarousal, avoidance and re-experiencing. Hyperarousal in early childhood is often observed through displays of inconsolable crying, flailing about, arching the back and biting. Hypoarousal involves emotional numbing that may be observed as a child who sleeps excessively, displays a dazed expression or averts his or her eyes. Avoidance is characterized by withdrawal, which is often demonstrated as displaying less affection, consistently looking away or avoiding facial contact. Other observable features of avoidance include a fear of being separated from caregivers, refusal to follow directions, disorientation and extreme sadness.

Re-experiencing is often the most subtle of the three symptoms, but it can be observed through the presence of rigid and repetitive patterns. These patterns can include common play leading to outbursts or withdrawal if the pattern is changed or interrupted. The play or reenactments have a noticeable anxious quality to them, or the child appears to space out when engaged in these patterns. One of the most consistent observations of re-experiencing is the presence of nightmares.

Neurological responses to traumatic stress include:

  • Increased levels of adrenaline (activation of the sympathetic nervous system)
  • Decreased levels of cortisol and serotonin (a reduced ability to moderate the sympathetic nervous system or emotional reactivity)
  • Increased levels of endogenous opioids (which result in pain reduction, emotional blunting and memory impairment)

In addition, chronic stress can interrupt cognitive functions such as planning, working memory and mental flexibility. Hence, it is important to systematically assess how children use relationships, interact with others and interact with their environment. Furthermore, when traumatic stressors deplete the coping resources of caregivers, they can become neglectful or show signs of chronic danger, leading to the potential disruption of the attachment system for young children.

Attachment issues

Attachment research describes children’s behaviors along a wellness spectrum from secure attachment (most well) to insecure attachment (where children are at highest risk). With secure attachments, caregivers display relaxed, warm and positive interactions involving some form of direct expression of feelings or desires and the ability to negotiate conflict or disagreement. In this manner, caregivers are encouraging, sensitive, consistent and responsive. With insecure attachments, the child loses confidence to varying degrees in the caregiving system, believing that the caregiver lacks responsiveness and availability during times of distress or trauma.

Securely attached children typically display the following healthy behaviors during the different phases of growth:

  • Phase I (0 to 3 months): Newborns often seek out connection (eye contact and touch) and respond to familiar smells, sights and sounds.
  • Phase II (3 to 6 months): Infants begin to orient to familiar people (preferring those who are familiar to them while avoiding those who are not familiar) and are emotionally expressive, responding to others’ emotional signals.
  • Phase III (6 months on): Infants become wary of strangers and actively seek out familiar caregivers. Additionally, they begin practicing verbal and nonverbal displays of happiness, sadness, anger and fear.
  • Phase IV (from the second to third year on): These young children notably gain increased abilities to negotiate with caregivers (sometimes resulting in short-lived tantrums), are better able to coordinate goals with others (showing adaptable and responsive goals), display increasingly empathic responses to others, and progressively develop greater walking and complex verbal communication skills.

Insecure attachments styles are divided into three categories: avoidant, resistant and disorganized-disoriented. Avoidant attachment styles often can be associated with caregivers who minimize the perceptions of young children, are emotionally unavailable, and assign care of the child to others. This results in young children becoming indifferent to the presence of the caregiver, displaying detached/neutral responses to others, and minimizing opportunities for interaction with others.

Resistant attachment styles are associated with caregivers who resist distress (showing avoidance verbally or physically) and often wait for the child to get highly upset before attempting to sooth. This conditions young children to maximize distress, to resist or display difficultly in being soothed, and to under-regulate their emotions (e.g., responding dramatically to change and acting out dramatically when expectations are not met). Additionally, these children readily perceive experiences as threatening, get frustrated easily, and often approach life anxiously or as if helpless. These children initiate their interactions with others through their distress.

The third and most unhealthy attachment style is disorganized-disoriented. It is associated with caregivers who are often confrontational, helpless, frightened or disengaged (avoidant). These caregivers often passively place children at risk due to the caregivers’ lack of involvement or preventive parenting skills. Their children respond by attempting to adapt to the caregivers’ emotional needs — either caretaking or avoiding. These adaptive behaviors are often observed as consistent displays of confusion, hostility, freezing responses or caregiving responses (e.g., reassuring, pleasing, cheering up).

Counselors’ role: As counselors, we are uniquely trained to meet the needs of young children because of our emphasis on human development, prevention, ecosystems and wellness. Counselors can use three main restorative skills to intervene with young children experiencing attachment issues related to traumatic stress. We can:

  • Set up a safe and warm environment in our clinical settings
  • Display trust through culturally sensitive gestures, tone of voice and facial expressions
  • Nurture a nonjudgmental understanding of young clients while focusing on exploration, empowerment and acceptance

By engaging in these three practices, professional counselors should be able to aid young children in working through a variety of social, emotional, behavioral and learning challenges. Counselors can foster warmth and vitality by employing mutuality and relational socio-dramatic play experiences. Additionally, counselors can create mediated learning so that young children can develop the ability to self-define, contextualize and transform their reality into healthy developmental journeys. This gentle, nonthreatening rebalancing of the energy can create restorative opportunities.

Ten evidence-based interventions

In 2000, Cirecie A. West-Olatunji (one of the co-authors of this article) and a colleague created a program called the Children’s Crisis Unit, in partnership with a local YWCA rape crisis unit, to provide clinical services to young children in a five-county area when referred for allegations of child sexual abuse. Over a four-year period, the Children’s Crisis Unit provided assessment and intervention for children and provided consultation to clinicians, law enforcement, medical professionals and legal professionals, both locally and nationally. During this time, training was provided for counseling, psychology and social work graduate students who learned how to work specifically with clients from birth to age 5.

The following techniques were used systematically with hundreds of clients. Although these interventions may be similar to those used with nonsymptomatic children, in working with young children, there are several unique features, including:

  • Assessment for degree of severity
  • Remediation
  • Involvement of the caregiver
  • Bookmarking for interventions at later developmental periods

1) Popsicle sticks: This intervention can be introduced in the first session with the primary caregiver and the child. One of the appealing things about the use of Popsicle sticks is that they are very inexpensive, meaning nearly any family can afford them. Counselors can use nontoxic crayons or markers and other craft tools such as glitter, buttons, yarn and nontoxic glue. Counselors direct the caregiver-child dyad to use the Popsicle sticks to create individual members of their family as dolls. This activity can be continued at home between sessions. This intervention facilitates bonding and trust, decreases anxiety, is client-centered and culturally appropriate, and allows children to tell their story.

2) Feeling faces: This activity provides easy access for the counselor because various versions can be downloaded from the internet. Use of the feeling faces allows children to identify with other children and their facial expressions. In the exercise, the counselor directs the child to select those faces to which he or she is drawn to determine thematic links between the selected faces. The counselor then hypothesizes and contextualizes the presenting problem. This activity is useful in remediating flattened affect, with the counselor directing the child to mimic faces that match a range of emotions.

3) Storytelling: Narrative activities allow children to tell stories of their own choosing or give a particular recounting as directed by the counselor. Storytelling also allows the caregiver to recount or read the child a story that represents some resolution to the problem. Additionally, this activity permits the counselor to a) read the child a story representing some resolution to the problem and then engage in dialogue about feelings or b) collect pre- and post-observational data regarding the child’s responses.

4) Puppets: This intervention is helpful in allowing children to use dramatic play to express their feelings, recount a story or “restory” prior negative events. It can be particularly useful when the caregiver is actively involved in the puppet intervention. Puppets can be of the caregivers’ own making or ones that are available in the clinical room. Smaller and isomorphic puppets work better with infants and toddlers, whereas 3- and 4-year-old children are more likely to respond to animal-shaped and larger puppets.

5) Anatomically and culturally correct figurines: These figurines can be useful in cases of physical and sexual abuse because children are more likely to provide an accurate accounting when directed to engage in dramatic play. This intervention allows children to reenact situations that they have experienced. Additionally, it offers opportunities for children to point to parts of the body on the figurines as well as on themselves. This activity can provide the counselor with an assessment of the child’s developmentally appropriate knowledge about sexuality.

6) Dollhouse: This intervention offers a physical example of the home that can be used to explain what happens in the home from the child’s perspective. Use of a dollhouse can aid in accessing the child’s memories more easily based on familiarity with household items rather than starting from scratch. This activity allows counselors to be either:

  • Directive with the child, using prompts such as, “Tell me what happens in this room” (while pointing to a specific room in the dollhouse)
  • Nondirective with the child, permitting the child to have free-flowing play with the items in the dollhouse (while making observational notes)

7) Play dough (modeling clay): Modeling clay provides a kinesthetic, moldable medium that children can use to contextualize and express feelings involving sensory experiences. This intervention permits children to create representations of their family members by providing definition to body parts and facial expressions, and thus connecting emotions, experiences and people to the critical event. Play dough activities allow counselors to direct children to mold important people (both family members and nonfamily members) in their lives.

8) Freehand drawing: This activity offers children the opportunity to creatively express what is happening for them in the moment. Tools for this activity are based on the child’s developmental level and might include crayons, markers, pens, pencils or chalk, depending on the child’s age and motor skills. Counselors can use this activity to promote comfort, connection, nurturance and fun for children.

9) Kinetic family/human figure drawing: Kinetic family drawing is a more directive technique that allows children to articulate how they see themselves in relation to other family members. This activity allows for dialogue between the parent and child in terms of perspectives of the family. The counselor offers paper and drawing instruments and directs the child to draw a picture of her or his family. (Note: Try to avoid stick figures, depending on the age of the child.)

10) In vivo parent-child observation and feedback: This intervention permits the counselor to assume an observer role as the parent and child interact. It can be either directive or nondirective. This activity allows for a real-time view of the interaction quality between the parent and child, providing insight into parenting style and skills as well as attachment issues. In vivo observations afford counselors the opportunity to prepare the clinical room with play materials and direct the parent to engage with the child (or, in a nondirective way, allow the parent and child to interact without instructions). Thus, the counselor can step back to observe (either in the clinical room or in an adjoining room with a one-way mirror). If the counselor is in the room, she or he can provide instant feedback and redirection, if necessary.

It should be noted that when working with preverbal children, counselors should rely on nonverbals such as body language, facial expressions, physiological responses and the child’s attention and focus. Also, be aware that children’s comprehension develops earlier than their language abilities. It is important to remember that children understand more than they can communicate.

Extending our reach

The counseling profession is poised to serve as a leading provider of much-needed services to young children. Our focus on prevention, environmental context, development and wellness makes us uniquely trained to assess, intervene with and investigate clinical issues in early childhood. The benefits for us as a profession are numerous and extensive.

First, by incorporating a focus on young children, we can increase our role definition by providing psychological consultation to children, parents, and child care providers in day care centers (such as Head Start) and preschools. Second, we move from the implicit to the explicit. Many practicing counselors are already working with young children in their agencies, schools and private practices. However, without counselor educators and policymakers explicating guidelines for practice, the profession lacks a systematic response to ensure application of evidence-based interventions. Third, we can expand our involvement in addressing the needs of this clinical population by securing grants from federal agencies and private foundations; attending think tanks and conventions where other health professionals are gathering to discuss the needs of young children; and advocating for increased coordination of service providers across all service delivery platforms and agencies. Finally, we can advocate for ourselves by becoming more visible within the larger health care community.

Recommendations: Existing courses in counselor education need to incorporate a paradigm that includes training specifically geared toward clinical populations from birth to age 5. The major challenge within this discipline is how to transform base-level skills into effective techniques and interventions for young clients.

School counselors especially need to have specialized skills and training so they are equipped with tools that acknowledge characteristics and cultural nuances that are specific to child populations. Allowing graduate students to become familiar with the pediatric population early in their training begins the process of conceptualizing young children in the context of a holistic, strength-based and culture-centered approach.

Some professionals have offered a solution to this dilemma by suggesting a framework that incorporates exposure to a variety of populations or the use of various subspecialties. In such a framework, counselor educators systematically incorporate broad content knowledge of specialized populations that is applied throughout the curriculum. Family courses could focus on the specific issues that pediatric members of the family system face and how these issues affect the entire family’s functioning. In addition, family courses could focus on interventions geared toward young children that incorporate the entire family, hence aiding the family to function more effectively. Counseling courses on theory and technique might add discussions on how to incorporate young child development and issues into concepts and interventions that are specific to various counseling theories.

Finally, to further develop our understanding of what practicing counselors actually do when working with young children, it is important to perform additional counseling research. One way of advancing our knowledge in this area might be the use of a Delphi study. This systematic approach, which would gather a panel of experts through a nominations process, could be used to generate ideas, gain consensus and identify opinions of a wide range of counseling professionals without face-to-face interaction. This method could provide a means of bridging research and practice to reach a common understanding of what steps can be taken to explore our conceptualization and assessment of and intervention with young children.

In sum, counselors have the ideal training to work closely with young clients and to provide culturally appropriate interventions to address the unique needs of this client population. Use of developmentally informed and ecosystemic frameworks will allow counselors to be accurate in their conceptualization and treatment of young children.

 

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Cirecie A. West-Olatunji serves as associate professor in counseling at Xavier University of Louisiana (XULA) and as director of the XULA Center for Traumatic Stress Research. She is a past president of the American Counseling Association and the Association for Multicultural Counseling and Development (AMCD). Internationally, she has provided consultation and training in southern Africa, the Pacific Rim and Europe. Contact her at colatunj@xula.edu.

Jeff D. Wolfgang is an assistant professor in the Department of Counseling in the College of Education at North Carolina A&T State University. His research focuses on multigenerational effects of trauma on young children and their families. Contact him at jdwolfgang@ncat.edu.

Kimberly N. Frazier is an associate professor in the Department of Clinical Rehabilitation and Counseling at the Louisiana State University Health Sciences Center-New Orleans. Her research focuses on counseling pediatric populations, cultured-centered counseling interventions and training, systemic oppression and trauma. She is a past president of AMCD and has served as an ACA Governing Council representative. Contact her at kfraz1@lsuhsc.edu.

 

Letters to the editor: ct@counseling.org

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

 

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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.