Tag Archives: youth

Helping youth in foster care cope with grief and abandonment  

By Lisa R. Rhodes  February 23, 2023

A teenager with a sad face sits on the grass and dreams of a better life in the sunset

Marian Fil/Shutterstock.com

Youth who are aging out of the foster care system frequently wrestle with feelings of grief and abandonment. Counselors who have studied the research literature or have treated this population for many years say the losses experienced by youths during the aging-out process can have a lasting impact on these clients.

“There are relationships that foster youth have with individuals in the system that are discontinued upon aging out. This can be a significant loss that needs to be grieved,” says Brian Russ, a licensed mental health counselor and an assistant professor in the Department of Counseling at Xavier University in Cincinnati. “Along with the loss of their childhood, these older adolescents and young adults can also feel a loss of hope for ever being adopted,” he explains.

Amy Watson, a licensed professional counselor supervisor in Dallas who has more than 20 years’ experience counseling children and youths in foster care, says these clients grieve what their lives might have been like if they never entered the system. However, these youths seldom reveal anything about what they have lost or experienced during their time in foster homes, she adds.

“These clients are definitely traumatized and go into fight, flight, freeze and fawn mode when triggered, which helps [to] temporarily protect them from further losses,” Watson says. “In counseling, we work on ways to manage triggers, process negative feelings and increase coping skills so they can get better at opening themselves up in future relationships.”

Providing unconditional positive regard

Russ, who has worked as a home-based clinician, outpatient coordinator and clinical director at Newaygo County Mental Health in White Cloud, Michigan, suggests that clinicians approach grief with this population by using person-centered therapy techniques.

“There are a lot of complex emotions that need to be processed, and a person-centered counselor can help by offering a safe, therapeutic environment that facilitates the core conditions of unconditional positive regard, empathy and genuineness,” he says. “In this environment, the client can process their emotions without feeling judged, which is necessary for the grieving process.”

Russ offers the following guiding thoughts that can help counselors when working with grief from a person-centered approach:

  • Detect and reflect. Grief often manifests outside of our awareness; therefore, it is important for counselors to detect the grieving process when it is less explicit. After identifying grief, counselors using the person-centered approach should reflect this to the client to help build awareness and establish an empathic understanding. For example, a counselor could say, “I sense a deep feeling of sadness inside of you. Could this be grief from your loss?”
  • Offer a safe space and go at the client’s pace. The counseling environment should be rooted in unconditional positive regard. The client should feel safe to express what they are feeling, and because the grieving process can be unique to each individual, the client should move at their own pace. In session, a counselor could tell the client, “I want you to feel like you can work through this grief in whatever manner you feel would be helpful and at whatever pace you feel comfortable. I want this to be a safe space to do this work.”
  • Help clients make meaning and express their feelings. The counselor’s role is to help clients discover their own meaning about what they are grieving. Clients should have the opportunity to express their feelings in their own way. Clients can have a cathartic experience by expressing their feelings in the therapeutic environment. To facilitate this, counselors could say, “I am curious about what this grief means to you. Do you have any thoughts?” or “Have you found ways of expressing your emotions in the past that have been helpful to you? I am wondering if that would be helpful to you in our session.”
  • Provide support until the end and don’t be afraid to start the process again. Allowing clients to work toward their own understanding and conclusion regarding their grief is at the heart of the person-centered approach. Clients may want to work toward accepting the loss or saying goodbye. Conversely, they may want to find a way for whatever they have lost to stay with them forever in some form. To help clients work toward their own conclusions, counselors could ask, “How do you feel about where you are at in regard to processing your grief?” or “Is there more work to be done?”

“Our job as counselors is to help the client find this conclusion, and I say ‘conclusion’ with the idea that grief may or may not have an end,” Russ observes. “Some grief lasts forever, and some grief may be cyclical. Either way, we support the client throughout the process.”

Russ says feelings of abandonment often go hand in hand with grief. “There is a loss with both phenomena, but abandonment may connect stronger to feelings of worthlessness,” he says. Allowing clients to “experience unconditional positive regard can help with worthlessness.”

Processing past emotions

Clinicians who work with youth who are aging out of the foster care system can help them to peel away the emotional defenses they have developed to protect themselves from hurtful people and situations. Watson says clinicians can use a cognitive behavioral approach to reframe clients’ thoughts by asking open-ended, empathic questions to start the process. For example, counselors might say:

  • Tell me about your losses and how you have coped with them.
  • What would you tell a young person entering foster care about losing siblings and family?
  • How has loss helped you to develop as a person?

“My clients have a hard time sharing about grief and sadness because they don’t feel safe and have a hard time being vulnerable,” Watson notes. “Once they build trust, they open up more and know I am safe for them. When youth[s] move around a lot, they lack consistency in relationships. Relationships are where youth[s] heal.”

Helping clients work through feelings of abandonment also better prepares them to form positive relationships in their present and future.

“Every person has a right to happy and healthy relationships with boundaries,” says Watson, a board member at WAY Alliance, a North Texas nonprofit dedicated to helping foster care youth transition to independence by providing mentors. “We live in a social world. … If youth do not work through abandonment, they will not have the skills or confidence to be open to relationships and roles throughout life.”

Watson used a trauma-focused cognitive behavioral approach when working with a 17-year-old young woman in foster care whose breakup with a boyfriend triggered feelings of abandonment from her past. The client had been in foster care for about three years, but child protective services had been involved in her life since early childhood when she was removed from her home of origin. She was then placed with an aunt until she was sexually abused by a relative while she was in her aunt’s care.

When Watson began working with the client, she was living in a group home that provided transitional living services. The client, who had also been sex trafficked, had feelings of low self-esteem and was desperate for the approval of men, which Watson describes as a consequence of her trauma.

“The past relationship with her boyfriend was age appropriate (unlike her past encounters with men) and had the boundaries of a normal consensual relationship. The client was especially disappointed because she finally had the experience of dating like the average teenager and felt it was safe,” Watson recalls.

In session, the client expressed negative statements such as “I’ll never have another boyfriend”; “I trusted him. I loved him. I thought he was different”; and “People don’t want me.” To help the client process her feelings of abandonment, Watson asked the young woman several self-reflective questions:

  • “How does the end of this relationship impact your self-image?”
  • “Can you see this breakup as part of normal dating rather than the belief that everyone is compatible?”
  • “How do you feel about the breakup now that some time has passed?”
  • “What would you tell someone going through a similar dating experience?”
  • “How does it feel to realize that your family was not there for you and did not protect you?”
  • “What has helped you cope with being on your own?”

With Watson’s help, the client began to view the breakup as an experience for personal growth rather than one of ruin and rejection.

“We discussed how she could take this time to focus on herself” and move forward, Watson says. The client noted in session that she wanted to grieve only for a week and then “be over it.”

Watson helped the client focus on her schoolwork, which she had been neglecting, and look for a job. They also discussed how she could put her energy into building other relationships — by talking to a staff person she was close to at the group home, for example.

Eventually, the client’s statements began to reflect a new sense of personal power, Watson says. She was now saying, “I know I need to be strong,” “I realize I need to get over this,” “I can’t let it stop me” and “I can’t let it keep me down.”

In a later session, the client “was also able to connect how abusive her trafficker was when she once thought he loved her and protected her and could now see she was a victim,” Watson says.

“This is a big step in healing,” she notes. “That’s all trauma processing. … The goal was for [the client] to find a way to build herself back up.”

Working on self-worth is vital for these youths whether they are recovering from grief, abandonment, or both. “Counselors can help youth with this by assisting them to discover their strengths and giving them opportunities to build self-esteem and self-worth by doing new things, taking risks and gaining confidence,” Watson says.


Learn more on this topic in the feature article “Counseling youth aging out of foster care” in the February issue of Counseling Today and in the online exclusive “Is Medicaid properly serving youth in foster care?

Lisa R. Rhodes is a senior writer for Counseling Today. Contact her at lrhodes@counseling.org.

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

Counseling youth aging out of foster care

By Lisa R. Rhodes February 3, 2023

A man waving goodbye to a teenager standing in front of a door waving goodbye


Rachel Jacoby, a licensed professional clinical counselor supervisor, once worked at a community mental health agency providing counseling services to youth in foster care. When she began treatment with an older teen, an unusual thing happened: The client referred to her as the number “14,” not by her name.

Jacoby says not using her name was the client’s way of reminding her that she was just another person in a long line of caseworkers and mental health providers they had worked with since being placed in foster care at the age of 3.

“They called me number 14 because I was the fourteenth counselor they saw,” Jacoby explains. Because of this history, the client assumed Jacoby wouldn’t be around for long and wondered why they should bother to build a relationship with her.

Jacoby, a member of the American Counseling Association, says the client’s response to her as a clinician is an example of the attachment problems that foster care youth, particularly those who are aging out of the system, experience.

“Instability is a very frequent experience in foster care,” Jacoby notes. She says she has known children in foster care who have been placed in more than 10 foster homes by age 9.

“If you’re going to build a relationship with a child who is living in foster care, … do your very best to stick around for the long haul,” she advises. “They need that. They depend on that.”

Facing difficult challenges

Jacoby, the current president of the Association for Child and Adolescent Counseling, a division of ACA, says children and youth are usually removed from their home of origin and placed in foster care by their state’s child protective services (CPS) agency if there is a report that their basic living needs are not being met or they are being abused or neglected. They can also be removed if CPS receives a report that their parents have mental health or substance misuse issues or that a parent or legal guardian has died.

And the number of children in foster care is significant. According to data by the Annie E. Casey Foundation, a total of 407,493 children and youth were living in foster care in 2020, and more than 20,000 youth left foster care without reuniting with their parents or finding a permanent home.

The goal of the foster care system is often to safely reunite children and youth with their parents or find them a permanent home with another family, but this gets more challenging the older the children are. Research shows that adolescents have a harder time being placed with a foster family. According to the report Keeping Kids in Families, published by the Annie E. Casey Foundation, only 58% of foster teens live with a family, compared with 95% of kids 12 and under, in 2017.

Chase Chick, a licensed professional counselor (LPC) in Dallas who works with foster care youth, says never getting adopted hits these young people hard and can often make it challenging for clinicians to connect and build trust with them in session.

Brian Russ, a licensed mental health counselor and an assistant professor of counseling at Xavier University in Cincinnati, says when a youth enters foster care, they may feel like something is wrong with them or their family. And this feeling that something is wrong with them or that nobody wants them may intensify if they do not get adopted.

“These feelings are strongly connected to worthlessness. As someone ages out, they may also have more mixed feelings,” Russ explains. “They may feel happy about their new freedom and autonomy. They may feel relief about leaving a system that has been traumatic. They may feel anxious and scared about being on their own without a safety net. They also may feel isolated and abandoned by losing their support system. It is complex and unique to each individual.”

Aging out of foster care can also bring additional hardships for these clients. According to the Annie E. Casey Foundation, one in five youth transitioning out of foster care report experiencing homelessness between ages 17 to 19, one in five have been incarcerated between ages 17 and 21, and nearly one in four report they became parents between the ages 19 and 21.

In addition, the counselors interviewed for this article say youth who are aging out of foster care are likely to have a history of abuse or neglect. In the article “Counseling adolescents aging out of foster care: A neglected and underserved population” published in the Journal of Counseling Research and Practice in 2021, Russ, along with co-author Taylor Tertocha-Ubelhor, stated that “foster youths’ mental health was their primary area of vulnerability because of the disruptions they had experienced during the early developmental stages of life.”

Whether youth are provided mental health services while they are in foster care largely depends on what state they live in, notes Jacoby, a visiting assistant professor in the Department of Counseling at Palo Alto University in California. She says some states provide counseling services and other benefits, while services from other states are more restricted.

Most children and adolescents are linked to counseling services when they are placed in a foster home, group home or other child welfare facility. They can also be referred to a community-based agency or practice that provides foster care counseling.

The management of state child welfare organizations also affects the level of care that youth receive in foster care. Russ and Chick say high turnover rates for caseworkers, due to heavy caseloads, and problems in reimbursing mental health practitioners for counseling services paid by Medicaid can also be factors. (For more on Medicaid and foster care, see a Counseling Today interview with Chick.)

Building rapport

Establishing trust and rapport with these youth is critical for the success of the therapeutic relationship. Clinicians must also be careful not to cause further psychological harm by using therapeutic techniques that focus on the adoption of an authoritative therapeutic stance or delving too quickly into the client’s past.

Calvin Young, a licensed clinical professional counselor in Illinois, says adopting an authoritative stance is counterproductive. “The goal of the clinician is to develop rapport with the client who has already been placed in a situation they may not wish for by authority figures, including the state’s child welfare authorities,” he explains. “An authoritative posture will not abet the development of trust or engender trust in the clinician as a neutral helper. An authoritative posture places the clinician in the role of another imperial authority who will not listen to or treat the individual involved with the child welfare or social system in a fair manner.”

Chick also advises counselors to move slowly and not press for therapeutic gains early in treatment. “A mistake that clinicians tend to make is they try to rush that process,” he says. “They try to get them [clients] to start spilling the beans right out of the gates.”

For example, Chick says asking about a youth’s experience with trauma too early can lead clients to lose trust and then hold back later down the line. Instead, he recommends counselors let clients come to them.

The counselors interviewed agree that clinicians need to be honest and genuine and not take themselves too seriously when building a therapeutic relationship with this population. They also need to be patient and wait for therapeutic gains and not be afraid to encounter resistance from their clients.

If a client has been in foster care a long time, they have learned to “read people real quick” and can easily spot someone who is disingenuous, says Amy Watson, an LPC and owner of a private practice that specializes in foster care counseling in Dallas. “They don’t trust you just because you’re a counselor. … They’re going to feel you out.”

She says these youth have adopted this skill of reading people quickly to maintain their own safety while adjusting to living in different environments and dealing with a revolving door of people in their life. For example, Watson’s says that about 80% of her clients who are aging out of the foster care system have experienced two to three failed adoptions.

Ebony White, an assistant clinical professor in the Counseling and Family Therapy Department at Drexel University in Philadelphia, says clinicians must know how to form a positive connection with others and they must be familiar with youth culture, specifically music, movies and social media.

Clinicians must meet these clients on their level and be able to engage in conversation, White says, often using the same lingo that young people use to communicate through texting (such as LOL or “periodt”).

White, an ACA member and owner of a group practice in Trenton, New Jersey, that serves children and adolescents, says it’s perfectly healthy if a youth is apprehensive or guarded when they begin therapy.

“I don’t believe anyone is resistant to treatment,” she explains. “When we label our clients as resistant, we’ve misjudged them. We’ve already put the onus of blame for their success or lack of success on their resistance.”

White says reticence on the part of these clients is natural, and they shouldn’t be influenced to behave any other way. “We’re asking them to disclose a lot about themselves, meanwhile we’re not telling them anything about ourselves,” she adds.

White suggests clinicians follow the example of “rolling with resistance,” a motivational interviewing technique that acknowledges that confronting someone does not always work and in fact may cause them to hold back or withdraw even more.

“Expect that it [resistance] will be present; it’s a natural part of the therapeutic process,” she says, encouraging her peers to ride the wave of resistance. “You follow the client’s lead.”

Young says cultural awareness and sensitivity are paramount in treating foster care youth, who are disproportionally represented in the foster care system. According to the Annie E. Casey Foundation statistics, Black children made up 20% of the youth entering foster care in 2020, yet they only represented 14% of the total child population in the United States, and Native American children made up 2% of kids entering care and only 1% of the total child population.

“The impact of foster care systems on communities of color in a negative way historically should be a primary grounding of the clinician who does not share the background of the youth in foster care,” says Young, an ACA member who has worked as a caseworker, supervisor and in a combination of clinical and administrator roles in social welfare programs. Primary grounding, he explains, is an overarching term that incorporates a person’s cultural, racial, ethnic, gender and socioeconomic background, which creates many of the unconscious biases that clinicians may bring to their work with clients whose appearance and background differ from their own. “Even counselors who share the same or similar backgrounds should be culturally aware and be constantly vigilant in regard to their own programmed biases,” he adds.

Facing trauma

The counselors interviewed for this article all agree that trauma is the most common mental health concern for youth in foster care. According to the Casey National Alumni Study, published in the Improving Family Foster Care report in 2005, former foster children were almost twice as likely to suffer from posttraumatic stress disorder as U.S. war veterans.

Chick, co-founder of Pursuit of Happiness, a group practice in Dallas that provides counseling services to youth in foster care, says the clinicians he works with at his practice have treated young people who are survivors of severe trauma.

“We have had kids whose family members killed each other in front of the kids. We’ve had kids with terminal illnesses in foster care who do not know about their fate and the referral source is relying on us as counselors to break the news,” Chick says. “Our job is to bring these young souls back into congruence with the person they are designed to be so that they can successfully participate in society.”

The counselors interviewed also say person-centered therapy, sand play therapy, reality therapy and cognitive behavior therapy can help these youth build a bridge from their trauma to a healthy self-image and a more hopeful future.

Russ, an ACA member who has worked as a home-based clinician, outpatient coordinator and community support services director at Newaygo County Mental Health in White Cloud, Michigan, says youth who are transitioning out of the foster care system most likely have received less unconditional positive regard, empathy and genuineness — the core tenets of person-centered therapy — throughout their time in the system.

“We need to provide a healthy dose of these core conditions to facilitate growth,” he explains. “Similar to how a plant needs sunlight, water and carbon dioxide to survive, humans need relationships with unconditional positive regard, empathy, and genuineness to thrive.”

He recommends counselors use a four-component, person-centered framework for engaging this population and helping them process trauma:

  1. Invite the client to share about their trauma when and if they want to. If they do share, it should be at their own pace.
  2. When a client shares something traumatic, respond with an empathic statement that lets the client know that you understand how they felt. For example, you could say, “My heart goes out to you during that time; it must have been really scary for you” or “I feel angry when you tell me this story. I imagine you were also quite angry at the time.”
  3. While a client is sharing their experiences, help them clarify their thoughts and emotions by using reflective statements such as “I hear you expressing hopelessness. Is that accurate?” or “I am curious about the thoughts you were having while that was going on.”
  4. Be sure to communicate to the client that you value them as a person no matter what they have done or what has happened to them.

Although play therapy is designed for young children, Jacoby finds it can help teens process their trauma as well. She says the use of sand tray therapy can be effective. She once worked with a teen who had been in and out of foster homes for most of their life. She explained to the client how sometimes it’s easier to share one’s story by creating a picture in the sand.

Jacoby provided various miniatures for the client to choose from to create their sand tray image. She first encouraged the client to spend time feeling the sand with their fingers to bring a sense of calm. Then she invited the client to gather the miniature items they felt most connected to and use them to create a picture. The client selected miniatures of beer cans (ones for a cake topper), a house and a bonfire.

The client grabbed all the miniature beer cans and threw them into a pile in the center of the sandbox, Jacoby recalls. They placed the house in a far corner of the sandbox and placed the bonfire between the house and the beer cans. The client then scattered the other toys and miniatures on the rest of the sand. When they finished, the client said, “This is what my life looks like. I miss my home, but this is what it looked like; it wasn’t safe.”

The client’s picture represented their experience within their home of origin, detailing their feelings of being unsafe, Jacoby explains. Before being placed in foster care, the client lived in an area that was heavily populated by gangs. The client’s parents had alcohol and substance misuse issues and they struggled to pay the bills. The family often went without water or heat.

This vivid picture of early childhood trauma opened the door for Jacoby to help the client adjust to new environments, advocate for what they needed to feel safe and develop coping skills to help them work through their traumatic experiences.

She then used person-centered therapy to talk about what made the client feel safe, and she used cognitive behavior therapy to help the client reframe their negative thoughts. Jacoby also introduced the client to mindfulness to help them learn how to be aware of their feelings in the present moment. And all of her clinical work with clients embeds a trauma-focused lens, she adds.

Focusing on what clients can control

White, who has worked as a clinician in a group home for female foster care youth ages 15 to 18, says reality therapy can be effective with teens who are aging out of the system.

“You don’t know how long you’ll be with them,” she says. So she often asks these clients, “What can I help you with for the time we have?”

Reality therapy, which was developed by psychiatrist William Glasser, is a type of counseling that views behaviors as choices. Some mental health professionals, White notes, are critical of reality therapy because the approach does not acknowledge mental health diagnoses or the use of psychotropic medications.

But White says this approach helps clients “feel empowered by focusing on what is in their control instead of what isn’t.”

The goal is to “help clients identify and connect or reconnect with others in a healthy and satisfying manner,” White explains. “To help clients avoid recycling the past [and] to move clients to positive change as they see it and support clients in identifying and implementing a plan to get their needs met.”

Practitioners of reality therapy use the WDEP system, which stands for wants, doing, evaluation and plan. This system involves asking clients a series of questions to help determine what they want in life and what they can do to achieve their goals. Some example questions, White says, include:

  • Is your behavior bringing you close to or further away from accomplishing your goals?
  • What stops you from getting what you want?
  • Who can help you get your needs met? How can I help you get these needs met?
  • What can you do to sustain this behavior?

White says she uses questions from the WDEP model to encourage youth to think, perhaps for the first time, about how they can leave their painful past behind and build a future all their own. And she measures the success of her clients based on whether “their behavior aligns more closely with their desires, they are having healthy, satisfying relationships, and they have an increased awareness about their needs and how to get them in healthy adaptative ways.”

Preparing foster youth for adulthood

Although these youth need to move forward in their journey of recovery by working to uncover and resolve emotional wounds, they must also acquire the basic life skills to function as adults.

“You would think that kids who have had a rough upbringing would be all hard and ready for the real world,” Watson says. “But they’re not. They’re unprepared for adulthood, and that’s the fault of the system.”

The counselors interviewed for this article agree that these youth desperately need to learn independent living skills, such as how to take care of basic personal hygiene, balance a checkbook, wash their own laundry, go grocery shopping, pay a utility bill, or complete a job application and create a resume.

In their study, Tertocha-Ubelhor and Russ noted that “before an individual exits the foster care system, federal legislation requires that sufficient transition planning and care coordination is provided to the youth in foster care through the development of an independent living plan.”
Because foster care caseworkers are often overwhelmed, helping youth create an independent living plan can be viewed as just another task on a very long list of things to do, Russ and White note.

“The literature also speaks of how the foster youth a lot of times feel disrespected in the independent planning process for transitioning out of the system,” Russ says. “A lot of times they don’t feel they have as many choices as they should have.”

He says foster care youth should be guiding the transition planning process, but when caseworkers get crunched for time, they spend less time gathering their clients’ input. This leaves youth “feeling like they didn’t have a voice in it,” he says.

White, founder of the Center for Mastering and Refining Children’s Unique Skills (MARCUS), a nonprofit that provides youth with tutoring, mentoring and mental health services, says the problem is that transitional plans are not sustainable for these clients. “They have this plan in their hand and then they’re out on their own,” she explains, noting that these youth need support to navigate housing, employment and health care systems.

While youth are in foster care, they rarely, if ever, make decisions about their own well-being, White continues. This is largely the job of caseworkers. However, once these clients age out of the system, they must often make important life decisions with very little guidance.

The current practice of developing transition plans is “not really preparing our young people to be successful,” White stresses.

Young says, if possible, counselors should refer these clients to employment counselors or other vocational skills testing or placement organizations and community groups that provide mentoring and related services so their adult living skills can be addressed.

“Given that many youths in foster care may find themselves without a community or family support system, any strategies that build and reinforce independence should be deployed,” he says, including career and vocational testing as well as psychometric testing.

The counselors interviewed agree that although these clients can face hardships, counseling can help them heal. “Meet them where they’re at, ask them what their needs are and don’t criticize them for their experiences or adjustments to life,” Jacoby advises. Instead, strive to “understand their stories.”


Resilience and reform in foster care

Counselors who are aware of the many trials older adolescents face when they age out of the foster care system say the resilience of these clients cannot be denied. Amy Watson, a licensed professional counselor in Dallas who has worked with children and youth in foster care for more than 20 years, says it has been “a wonderful privilege” to work with this clientele.

“I wouldn’t want to work with this population of kids if it were all dreary and dark or if I never saw anything good happening,” she notes.

Many of Watson’s former clients who have aged out of foster care went on to become the first in their family of origin to graduate from high school or college. Others grew up to be healthy, loving parents who do not abuse their own children.

“I just see wonderful people thriving because they’ve made that commitment to themselves to make better choices,” Watson says. In fact, her clients often tell her that they are going to “break the chain” and not be like their parents.

The possibility for positive life outcomes such as these highlights the need to revamp the foster care system. Viewing foster care through a trauma-informed lens is critical, notes Brian Russ, a licensed mental health counselor in Indiana and Michigan.

“Without a trauma-informed philosophy, the foster system would be ignoring perhaps the most notable concern that foster youth experience — trauma,” he stresses. “Children are removed from their home often due to trauma. The removal process can be traumatic. And living in the foster system itself is full of transitions and uncertainties, all of which can be traumatic.”

Russ helped train mental health professionals, educators and law enforcement personnel in trauma-informed systems of care during his tenure as the community support services director at Newaygo County Mental Health in White Cloud, Michigan, from 2015 to 2018.

“By recognizing these traumas and making active attempts to mitigate them, a trauma-informed foster care system would provide a better environment for foster care youth to succeed,” says Russ, now an assistant professor in the Department of Counseling at Xavier University in Cincinnati. “This reform is more than a suggestion; it is an imperative.”

He stresses the need for counselors to advocate and work for change in the foster care system. “People are amazing. People can overcome a ton. We just can’t write someone off because they were in foster care,” he says. “One positive long-term relationship with a caring adult can be a mitigating factor for a lot of [these] concerns.”


Lisa R. Rhodes is a senior writer for Counseling Today. Contact her at lrhodes@counseling.org.

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.

Is Medicaid properly serving youth in foster care?

Compiled by Lisa R. Rhodes January 31, 2023

Paper cutout family with house under a Medicaid umbrella


Older youth who are transitioning out of foster care face many mental health challenges such as trauma and attachment and trust issues. In addition, they grew up in a flawed foster care that often results in the youth who have experienced multiple placements in different foster homes, overwhelmed caseworkers and poor planning for transitional living to adulthood.

Most children and youth in foster care are eligible for Medicaid, with individual states determining eligibility criteria within federal guidelines. Data from the Children’s Defense Fund shows that Medicaid covers over 99% of children in foster care and that up to 80% of children entering foster care have a significant mental health need. However, reimbursement problems associated with Medicaid often lead to a disruption of mental health services for these youth.

Q&A With Chase Chick

Chase Chick, co-founder of Pursuit of Happiness in Dallas, spoke with Counseling Today about Medicaid’s deficiencies in serving counseling agencies that work with youth in foster care and the steps his practice is taking to reform Medicaid for foster care youth in Texas and around the country.

What is the capitation rate model of Medicaid and how does it work?

The capitation rate model is a perverse idea on its face. The government, rather than implementing health care themselves, gives giant lump sums of money to commercial insurance companies called, you guessed it, a capitation rate. The insurance companies derive their profits based on what they do not spend. You can certainly draw your own conclusions about why this is a prima facie bad idea.

What are the main problems your practice has encountered under this model?

Inappropriate claim denials, unending audits, delayed payments, no payments at all, failing to enroll providers in a timely fashion. The list goes on and on. The fun part is when a counselor who pours their heart and soul into this population starts getting inappropriate claim denials and has to tender their resignation against their own wishes. What follows is a disruption of services (if we can even find a replacement counselor in time to resume services at all) with a vulnerable kid who doesn’t deserve to have their counselor quit on them. The lack of consistent counseling is precisely the No. 1 reason why these kids far too often become statistics.

What steps is your practice taking to correct these problems?

We have made numerous complaints to the Texas Health and Human Services Commission (HHSC) about the issues. The problem is that HHSC is slow to act, if they act at all, and they often side with the insurance company. When HHSC actually bothers to correctly side with us, too often the claim denials have already impacted the counselor and they have already resigned. It’s a pretty hollow feeling getting claims paid to a counselor who has already moved on. The damage is already done, but worse still, the damage to the foster kid is immense. Usually, these kids show up at psych hospitals after a suicide threat or a meltdown and the caregiver calls Child Protective Services (CPS) or the placement agency and tells them they’ve had enough and to come and get the kid. From there it’s off to a residential treatment center or sleep in the CPS offices. And from there it’s statistics time.

Anyone want to take a guess on how well a foster kid does after having their caregivers quit on them with nowhere else to go but sleeping on the floor of a CPS office? The worst part? We had a chance to get a good counselor in front of this kid who could have made a difference. We had the referral. We had the counselor. We had the kid scheduled. But instead, the capitation rate model claim[ed] another victim. Rinse and repeat.

What are your goals in bringing this matter to legislators on Capitol Hill?

We absolutely have to get the insurance companies out of the driver’s seat, especially when it comes to mental health. During one conversation with a particular insurance company, we were told we were wrong for rendering individual and family counseling on the same day, despite the fact that in addition to working with the kid individually, helping integrate the kid into the family unit is something that CPS caseworkers and placement agencies often beg us to do in order to avoid disruption.

Our legislative proposal offers a beautiful fix in that it follows the precedent of the Saint Anthony Hospital v. Eagleson decision from Illinois in correctly naming the state as the one ultimately responsible for implementing Medicaid. The kicker is that it will work out to be a revenue positive for the state, which is always a legislative concern when scoring the impact on the governmental budget.

I’m not sure if I want to get into the mechanics of how it actually works at this time because the insurance lobby is extremely well funded, but it would be a giant leap toward making sure that the days of inappropriate claim denials and other antics are a thing of the past.

We’re a great organization [that] specializes in what I believe to be a population that presents us the best opportunity to spread the most amount of good. Our counselors do exceptional work and pour everything they have into these patients. Making sure they are paid for their work rather than being cheated out of their hard-earned pay should be a priority at the top of every list.

Medicaid and Medicare combined are twice the budget of the United States military, and as such, [this] is a very expensive issue. Making sure these taxpayer dollars are respected and utilized as they should be rather than a money-making scheme for insurance companies should enrage every single person in the United States. We all live in this society together. The Medicaid program is supposed to be a tool to make sure that the most vulnerable among us have an opportunity to become a contributor to society. With the current capitation rate model, the best I can say is good luck.


Read more about the challenges faced by older youth in foster care in Counseling Today‘s February feature article, “Counseling youth aging out of foster care.”


Lisa R. Rhodes is a senior writer at Counseling Today. Contact her at lrhodes@counseling.org.

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 youth who self-harm

By Bethany Bray January 10, 2023

A teenager wearing a mask sits on stairs with her chin and hands resting on her knees. The teenager is looking straight head into the camera. A bookbag sits beside the teenager.

Ground Picture/Shutterstock.com

Self-harm behaviors in American youth rose sharply during the peak of the COVID-19 pandemic and continue to be a concern among counselors who work with children and adolescents.

In early 2021, FAIR Health completed an in-depth analysis of insurance claim records to compare changes between 2019 and 2020. The New York City-based nonprofit found the mental health claims for individuals between the ages of 13 and 18 doubled between March and April 2019 and the same months one year later.

That same age group saw a startling increase — nearly 100% — in the number of insurance claims for medical care received for intentional self-harm between April 2019 to April 2020. And the Northeastern United States (Connecticut, Maine, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island and Vermont) saw the highest spike in claims for treatment of injuries in teenagers from intentional self-harm — a 333.93% increase — between August 2019 and August 2020.

This data tracks with what many counselors are seeing in their own caseloads: An increase in young clients who turn to self-harm to cope with the stress and upheaval that came — and continues to come — with the COVID-19 pandemic.

There is a strong correlation between social isolation and self-harm, notes Deanna Dopplick, a licensed professional counselor (LPC) at S.A.F.E. (Self Abuse Finally Ends) Alternatives, an outpatient program that specializes in treatment for nonsuicidal self-injury (NSSI) in St. Louis. As hard as it was for children and adolescents to have decreased connection with peers while schools were closed during the peak of the pandemic, it’s been equally challenging for them to return and reintegrate to the social dynamics of in-person school, she says.

Dopplick, an American Counseling Association member, is among the many practitioners who are seeing an uptick in client referrals for self-harm among children and adolescents. Her organization has “struggled to keep up” with the need for services, she says, and unfortunately, many prospective clients sometimes end up on a waiting list. In addition to new clients, Dopplick says she’s also seen an increase in relapses among clients who have returned to self-harm behaviors to cope after making progress in therapy previously.

As more counselors see youth who self-harm on their caseloads, Dopplick urges practitioners to focus on empathizing with these clients and fostering a trusting therapeutic relationship. The worst thing a practitioner can do, she says, is to panic or act fearful when a client discloses the behavior or dismiss it as attention-seeking.

“I have seen clients that have been in therapy for months or even years [before coming to SAFE], and the behavior has been so protected and shameful that they haven’t disclosed it. There is a stigma that self-injury is weird or different or ‘crazy.’ It’s not something that’s easy to open up about,” says Dopplick, who provides individual and group counseling for clients 12 and older. “We [counselors] need to make sure we’re meeting the client where they’re at, humanizing them and validating their experience. … It [self-harm] is so much more common than people think, and it doesn’t make [the client] scary or different. Empathy goes a long, long way with these clients.”

A way to cope

Michael Visconti is a licensed mental health counselor who treats children and adolescents in private practice in Boston. He estimates that one-quarter of his caseload at any time is exhibiting self-harm behaviors — a proportion that rose to roughly 50% during the peak of the pandemic. Many of these clients are referrals for self-harm from a local pediatric medical office.

The youngest client Visconti has counseled for self-harm behavior (in the form of intentional head banging) was six years old, but he finds it’s most common in younger teenagers, ages 12 to 15, he says.

Like Dopplick, Visconti emphasizes that there is a “direct correlation” between social isolation, feelings of hopelessness and self-harm behaviors in youth. “The more isolated an individual is, the less they feel they can reach out to others and express that emotion, so they turn inward,” Visconti explains. “Most often, it’s a maladaptive form of coping.”

While the intense isolation that occurred during the peak of the pandemic has lessened, all the same stressors that youth experienced before the pandemic (such as abuse, neglect or trauma at home, negative body image, social pressures and negative messaging on social media) remain, he notes.

In Visconti’s experience, the reasons that drive youth to self-harm often fall into a few common categories:

  • Managing emotions: When feelings are strong and uncomfortable, adolescents and young clients sometimes find it easier to experience physical pain rather than emotional distress. Self-harm offers an immediate and effective means of emotion regulation in the short term. Visconti says that in his experience, this is the most common pathway to self-harm.
  • Communicating: Some individuals make use of self-harm to outwardly display their emotional pain because they don’t have the means or opportunity to put it into words. This can be especially common among youth who live in invalidating family and home environments, Visconti says.
  • Punishment: Young clients sometimes turn to self-harm to punish themselves and “confirm” and internalize the negative narrative they have about themselves, Visconti says. These clients often believe that they are the problem and reason for their unhappiness, and self-harm is a way to reinforce these feelings. This is common among youth with poor self-esteem and/or a trauma history, he adds. Dopplick also finds that young clients who self-harm often struggle with intrusive thoughts that are intensely negative, such as “I am bad,” “There is something wrong with me” or “I am a disappointment,” so she spends a lot of time focusing on redirecting self-talk with clients at her program.
  • Seeking control: Some young clients turn to self-injury as a means to exert control in their life, albeit in a painful way. It can be a maladaptive way to find autonomy, Visconti explains. This was the especially the case when many youths felt that the “fundamentals of their life had been stripped” away during the pandemic, such as the routine of the school day, social activities, extracurricular activities and other things they enjoyed.

Asking the right questions

The crux of what defines NSSI is the intent behind the behavior, Visconti explains. Self-harm can be an impulsive phenomenon as well as something that is very deliberate, planned and well thought out. Visconti says that it’s not uncommon for him to see young clients who have created a self-harm “kit” for themselves, complete with harming tools as well as items to disinfect and treat wounds afterward.

When assessing for self-harm, counselors should not hesitate to ask clients directly about whether an injury was deliberate to determine intent, Visconti says. He often uses questions such as “Was that [injury] purposeful?” or “Did you place yourself in that setting with the hope that it harmed you?”

That second question can help uncover behaviors that are beyond the common ones that counselors may think of, such as cutting or burning. For example, Visconti once had a young client who slept on a mattress that had a metal spring poking out of it, and he purposely didn’t tell the adults in his life about it because he hoped that it would cut and injure him while he was in bed.

Asking questions about intent can also help uncover behaviors that a client has kept hidden or that escape the notice of peers or adults in a client’s life.

Dopplick has also seen self-injury behaviors that are outside of what a counselor may expect. This includes keeping a (non-self-inflicted) wound from healing, hitting or biting oneself, inserting objects under the skin, ingesting things that the client knows are toxic or dangerous (such as glass or household cleaners), head banging, hair pulling, picking of skin or nails and other behaviors.

In sessions, asking clients questions to determine the frequency and severity of self-harm impulses and actions is vital to understand the context of their behavior and level of risk, Dopplick says. For example, a client who has self-injured twice by a single method (i.e., rubbing themselves with an eraser to the point of burning) will need a different response than an individual who has injured themselves 100 times or uses multiple methods (e.g., cutting with a razor blade, punching walls).

Understanding the full context of a client’s NSSI can help a counselor identify the reasons why they engage in the behavior and, ultimately, personalize and tailor treatment to meet their needs. Dopplick encourages counselors to ask clients a range of questions, including:

  • Have they ever received medical attention for NSSI or needed attention but didn’t seek it?
  • What tools are they using to injure themselves? Do they have access to these tools?
  • How often are they engaging in self-injury?
  • Are their harming behaviors usually impulsive or preplanned?
  • Does anyone else, such as a parent or a friend, know that they’re self-injuring?

“Having the impulse to injure is different than following through with action,” Dopplick adds. “They may have impulses every day but may only injure once per week. It’s something to ask about: How are they managing their impulses?”

She recommends counselors ask clients to keep a log to track situations when they felt the urge to self-harm or engaged in self-harm, which she says can be helpful in therapy because it can shed light — both for the client and the clinician — on patterns. Dopplick encourages clients to record what they were doing and feeling before, during and after an urge to self-injure to help identify triggers.

Although NSSI is distinct from suicidality, the counselors interviewed for this article note that it’s important to assess clients who self-harm for suicidal intent because the two issues can sometimes overlap.

Visconti uses the Columbia-Suicide Severity Rating Scale and recommends it as a helpful way to screen both for suicidality and self-injury and parse out the intent and severity of a client’s behavior. The tool’s questions can help determine how chronic a client’s behavior and feelings are, he explains, and it can be easily used with many different client populations and treatment settings.

Discussing self-injury with a young client can be uncomfortable or worry-inducing for a clinician, Dopplick and Visconti admit. However, it’s vitally important for counselors to complete a thorough assessment to determine a client’s level of risk without becoming panicked and jumping to crisis response, such as talking about hospitalization.

“If you [the counselor] seem scared or overwhelmed or go straight into crisis mode, you won’t get all the information you need from the client,” Dopplick stresses. And “that will make them very hesitant to disclose self-injury again.”

She encourages counselors to keep an open mind when asking clients about their self-harm behaviors. Making assumptions about the factors that contribute or the reasons why they are engaging in NSSI “is the best way to shut down the conversation,” Dopplick adds.

Instead, “see the client as the expert on themselves and their behavior. Do not criticize, minimize [the behavior], come off in a punitive way or assume they’re doing it for attention or because their friends are doing it,” she stresses. “Really put the client in the driver’s seat instead of coming at them with assumptions.”

Finding healthy ways to cope

At its core, NSSI indicates that a client has unmet needs, Dopplick says. A counselor’s role then is to help the client identify and understand those needs and find ways to meet them without turning to self-harm.

“No one self-injures for no reason; there’s always an underlying reason, a function,” she notes. “For most clients, it [self-harm] is something that they’re hiding, something just for them, something that ‘helps’ them.”

Dopplick says that the counseling groups she leads for self-injury spend the majority of the time talking about the context and circumstances surrounding their self-harm, rather than the actual behavior. For young clients, this often includes the pressures their parents put on them or stress related to school or social relationships.

“We talk about the why and how more than the what,” Dopplick says. “The self-injury is not the actual problem; it’s what’s underneath it. All the underlying stuff — the why — is the problem, and [counselors] can miss the boat if [they] don’t explore it.”

Paige Santmyer, an LPC who works with teens and adults at a Christian counseling practice in the Atlanta area, agrees that helping clients identify what triggers their urge to self-harm is an important first step, followed by creating a plan to replace the behavior with healthier options. It also helps to identify the perceived “reward” they seek in self-harm, she says, to tailor a client’s treatment plan and coping mechanisms.

For example, if a young client struggles with feeling numb and turns to cutting themselves to feel something, Santmyer says she would teach the client mindfulness and guided imagery techniques that can help them connect to how they’re feeling. Or, depending on the client, they might respond to something creative such as using virtual reality to “go” hiking or zip lining to redirect and energize themselves, she suggests.

Young clients will need activities and techniques at the ready to replace the urge to self-harm; planning ahead is key. Santmyer brainstorms with clients to identify ways they can seek connection and soothe themselves when needed, such as doodling or drawing or talking to an accountability partner.

She also finds it helpful to have young clients create a “distraction box” filled with special or favorite items that can help to self-soothe and take their minds off the urge to self-harm. These items can include art, knitting or crochet supplies, essential oils, a favorite lotion, coloring or puzzle books, pictures of loved ones, an object with beads for counting or a kaleidoscope to look through. (For more on creating self-soothing kits with clients, read the Counseling Today online exclusive “Regulating the autonomic nervous system via sensory stimulation.”)

Similarly, Visconti says he focuses on helping young clients who self-harm find ways to redirect themselves away from the urge to injure. He gives clients a worksheet with 100+ ideas from Matthew McKay, Jeffrey Wood and Jeffery Brantley’s The Dialectical Behavior Therapy Skills Workbook: Practical DBT Exercises for Learning Mindfulness, Interpersonal Effectiveness, Emotion Regulation & Distress Tolerance to spark ideas and keep for future reference. Depending on the client’s age and needs, activities could include playing video games, visiting a friend, eating their favorite flavor of ice cream, writing a song, using an app to learn a new language, getting a haircut or painting their nails.

Managing distressing emotions

The counselors interviewed for this article agree that while clinicians need to tailor their work to fit their clients’ individual needs, many young clients who self-harm will need some combination of treatment that challenges negative self-talk and strengthens distress tolerance and emotion recognition and regulation.

Santmyer says that it’s common for young clients who struggle with NSSI to be disconnected from and confused about their emotions.

She focuses on emotion recognition with clients by asking them to think about where they feel strong emotions in their body and prompting them to talk about what it feels like and how they usually respond to those sensations. She also finds cognitive behavior therapy (CBT) helpful to guide clients to explore, challenge and reframe the fears and negative core beliefs that drive feelings such as worthlessness or perfectionism that trigger an urge to self-injure.

“Helping them understand and name the emotion they are feeling helps clients feel more in control of themselves instead of feeling compelled to manage the sensation itself through self-injury. Counselors can also use CBT to build insight into how emotions are giving them messages, how they can interpret them in positive or negative ways, and how those interpretations lead them toward or away from self-injury,” explains Santmyer, an ACA member. “Ultimately, clients will need to understand how they are perpetuating their self-injury cycles and practice changing their negative thoughts to change their self-harming choices into more thoughtful and healthy responses.”

Santmyer and Visconti also noted that dialectical behavior therapy (DBT) can be especially helpful to use with young clients who self-harm because of its focus on emotion regulation and distress tolerance. (Santmyer and Visconti are not certified in DBT but have studied it and draw from the method in their work with clients.)

DBT is a good fit for this client population because it’s practical and effective in a short amount of time and it teaches much-needed skills and coping mechanisms to manage stress and tolerate uncomfortable feelings, Visconti notes. In fact, he says he’s seen DBT techniques spark growth and healing in self-harm clients right away because of the skill-building component.

However, DBT is most helpful for clients who self-harm as an emotional outlet, rather than those who use the behaviors to communicate or exhibit their emotional pain, he adds.

Santmyer finds that the ACCEPTS skill from DBT is particularly helpful to strengthen clients’ ability to overcome distressing emotions and situations without turning to self-harm. This tool guides clients to think about or engage in:

  • Activities: Do something that requires thought and focus, such as writing in a journal, to shift their attention away from distressing emotions.
  • Contributing: Do something that involves focusing on other people (e.g., sending a card, asking a loved one about their day, doing volunteer work).
  • Comparisons: Put their situation in perspective by comparing it to something more painful or challenging, including thinking of a time when they were in greater distress and got through it.
  • Emotions: Find a way to disrupt the emotion they are feeling (e.g., angry, sad) and replace it with a different or opposite emotion (e.g., going for a walk to calm oneself, watching a happy movie).
  • Pushing away: Use a technique such as guided imagery to block painful feelings from their mind and delay the urge to self-harm.
  • Thoughts: Use a strategy to shift one’s thoughts to something neutral (e.g., counting backwards, reciting song lyrics, naming objects around them that start with a certain letter of the alphabet).
  • Sensations: Engage in activities that trigger safe sensations that distract them from distressing emotions (e.g., eating something spicy, feeling the water on their body during a shower).

Trust and validation

Getting to know the client and tailoring treatment to their individual needs must take priority when counseling youth who struggle with NSSI, Dopplick says. She suggests that practitioners first find ways to connect with clients — particularly those who have been referred to counseling specifically for NSSI — and talk about topics other than self-injury to forge a trusting relationship.

Believing the client and validating their experience and pain should be the counselor’s No. 1 priority, she stresses. Only then can a counselor begin to identify and delve into the reasons underneath their self-injury.

“Often [these clients] feel that no one understands or validates their pain, and they are compelled to continue self-harming as a way to express in their body what they feel they cannot express verbally,” Santmyer says. “The validation and compassion of the therapist will bring the safety that young clients need to explore the drivers of self-harm.”

Dopplick finds that she’s sometimes the first adult to tell a young client that she understands why they are distressed to the point of needing to self-harm or to emphasize that they’re not weird or “crazy” for engaging in NSSI. After validating the client’s experience, she explains that she can help them find other ways to cope.

It’s vital for counselors to keep an open mind and accepting demeanor with these clients, Dopplick stresses. “There’s a huge difference between expressing your concern in a caring way, rather than asking 1,000 questions and focusing on” a client’s self-harm behaviors, she says. “It’s important to approach it with curiosity. … They know themselves and know what this behavior does for them; you just have to help them figure that out, and then build off of that to get more information.”

When working with young clients who self-harm, Visconti says he makes sure to acknowledge how hard it is to disclose and discuss such a painful and deeply personal topic. He thanks them for trusting him with such vulnerable information and feelings. “I empathize [with clients], commiserate and then try and bring about a sense of hope and preservation,” he adds.

The most important technique a counselor can use with these clients is the therapeutic relationship itself, Visconti says.

He admits that young clients who engage in self-harm can be challenging, not only because it’s an uncomfortable topic to address but also because they often have multiple presenting concerns or mental health challenges.

However, he pushes back against the misnomer that talking about self-harm in therapy can increase the behavior, retraumatize or cause emotional harm for a client. Counseling involves delving into many different types of painful topics, he says, and the key is for practitioners to handle it with openness and warmth.

“The long-term benefits greatly outweigh that distress,” Visconti emphasizes. “It’s so crucial to the betterment of their client, and you’re not going to increase the likelihood [of NSSI] by talking about it — it doesn’t work like that.”

Challenges that can co-occur with nonsuicidal self-injury

Depression and anxiety are the most common diagnoses that can co-occur in young clients who engage in nonsuicidal self-injury (NSSI). However, there are many other challenges that individuals may struggle with simultaneously.

There is a high correlation between NSSI and eating disorders, as well as clients who have experienced trauma, particularly sexual trauma, as self-harm can be a way for these individuals to seek control, disconnect or cope with painful feelings, trauma flashbacks or the stress of continuing to live in an abusive environment.

It also can co-occur with obsessive-compulsive disorder in clients who use self-injury to satisfy urges for repetitive behaviors to manage or communicate distress. This can also be the case for individuals with autism.

“It’s very effective to disconnect: To disconnect with their brain, with their body and overwhelming feelings, and this [self-injury] gets it to stop. But that’s also one thing that makes it hard to stop doing,” says Deanna Dopplick, a licensed professional counselor at S.A.F.E. (Self Abuse Finally Ends) Alternatives, an outpatient program that specializes in treatment for NSSI in St. Louis. “A lot of people think of self-injury as this impulsive thing, and it can be, but it also can be very obsessive. If they [a young client] can’t manage their stress at school, they may be thinking all day about injuring once they get home.”

The relief and other satisfactions that an individual seeks from self-harm lessen over time, which sometimes causes individuals to increase the self-harm behaviors and, eventually, turn to other risky behaviors, such as sexual promiscuity, restrictive eating or using substances, to seek similar feelings of reward or relief. So counselors who work with clients who disclose self-injury behaviors (or a past history of NSSI) should also screen for substance use, suicidal ideation, eating disorders, behavioral addictions and other high-risk or destructive behaviors.

This information came from an interview with Deanna Dopplick, a licensed professional counselor at S.A.F.E. (Self Abuse Finally Ends) Alternatives (selfinjury.com).

Supporting parents of young clients who self-injure

Counselors who work with children or adolescents who self-injure are in a position to offer support to adults in the client’s life who are misunderstanding or anxious and upset about the child’s behavior.

Understandably, parents often panic and experience intense worry when they find out their child is self-harming, says Deanna Dopplick, a licensed professional counselor at S.A.F.E. (Self Abuse Finally Ends) Alternatives, an outpatient program that specializes in treatment for nonsuicidal self-injury in St. Louis. Often, parents’ first response is to enact punishment, such as taking the child’s cellphone away to cut off contact with friends or locking up all the sharp objects in the home.

However, this won’t stop the child’s self-harm behavior — it can actually increase it, Dopplick says. A punitive response from the adults in a client’s life will only cause the child or adolescent to feel even more shame about their self-harm, and it can lead them to engage in harming behaviors that are more hidden and secretive. This includes injuring themselves in ways that won’t leave a mark or on parts of the body that are usually covered by clothing.

It’s also not helpful for parents to reward a child for going a length of time without injuring themselves, she adds. Counselors can offer psychoeducation to parents on why the punishment-reward cycle is not effective in situations of self-harm, and they can provide healthier alternatives.

“We have to remember that it [self-harm] is a coping mechanism. It’s not a healthy one, but it does not mean that the child is ‘bad,’” seeking attention or acting out, Dopplick stresses.

She finds that the book Healing Self-Injury: A Compassionate Guide for Parents and Other Loved Ones by Janis Whitlock and Elizabeth Lloyd-Richardson is a helpful resource to recommend to parents. The book offers guidance on ways parents can talk to their child about self-harm and support them in a healthy way. (Whitlock, one of the co-authors, is the director of the Self-Injury & Recovery Resources research program at Cornell University; Dopplick notes that Whitlock’s entire body of research can be helpful to counselor practitioners who want to learn more about the topic of self-harm.)

Parents often jump to the assumption that self-harm behaviors mean that their child is suicidal, says Michael Visconti, a licensed mental health counselor who treats children and adolescents in private practice in Boston. Research indicates that the majority of individuals who self-harm do not have suicidal thoughts, he notes.

So counselors can educate parents on the differences between suicidal ideation and self-injury and assure them that although self-harm behaviors are concerning, they don’t necessarily mean that their child wants to end their life, Visconti stresses.

Bethany Bray is a former senior writer and social media coordinator for Counseling Today.

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.

Supporting transgender and gender-expansive youth

By Cortny Stark July 29, 2022

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

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

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

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

The current crisis

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

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


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

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

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

A call for advocacy

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

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

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

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



Cortny Stark

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


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