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Counseling
Children & Adolescents
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Counseling
Children & Adolescents
Fifth Edition
Ann Vernon and Christine J. Schimmel
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Copyright © 2019 by Cognella, Inc. All rights reserved. No part of this publication may be reprinted, reproduced, transmitted, or utilized in any form or by any electronic, mechanical, or other means, now known or
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Dedication
This book is dedicated with love to my grandchildren, Elia and Niko Kavic Vernon, whose vibrant
and unique personalities never cease to amaze me! They are creative, loving, and exceptionally
perceptive. I look forward to watching them navigate their journey through life. —Nanna (Ann)
This book is dedicated to my son, Austin. Thank you for letting me help you navigate the challenges and trials that many children and adolescents face in our world today. It has been my
greatest honor and my most rewarding achievement to watch you grow into the fine young man
you are today. —Mom (Chris)
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Brief Contents
Preface
About the Editors
About the Contributors
xv
xix
xx
CHAPTER 1 Working with Children, Adolescents,
and Their Parents: Practical Applications
of Developmental Theory
Ann Vernon and Pei-Chun Chen
1
CHAPTER 2 The Individual Counseling Process
Sarah I. Springer, Jean Sunde Peterson,
Lauren Moss, and Ann Vernon
CHAPTER 3
Creative Arts Interventions
Ann Vernon
CHAPTER 4 Play Therapy
Rebecca Dickinson and Terry Kottman
CHAPTER 5 Solution-Focused Brief Counseling
Russell A. Sabella
CHAPTER 6 Reality Therapy
Robert E. Wubbolding
CHAPTER 7 Rational-Emotive Behavior Therapy
Ann Vernon
37
75
111
147
185
222
CHAPTER 8 Counseling Children and Adolescents
With Exceptionalities
Tori Stone and Pamelia E. Brott
258
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CHAPTER 9 Counseling Children and Adolescents
From Diverse Backgrounds
Darcie Davis-Gage
CHAPTER 10
hildren and Challenges: Counseling from a
C
Growth Mind-set Perspective
Monica Leppma & Christine J. Schimmel
(with contributions by Anna Simmons)
CHAPTER 11
300
Counseling At-Risk Children and Adolescents
Jennifer E. Randall Reyes and Monica Leppma
CHAPTER 12 Small Group Counseling
Christine J. Schimmel and Ed Jacobs
CHAPTER 13 Working With Parents
Ann Vernon and Monica Leppma
338
380
418
457
CHAPTER 14 Working With Families
Katherine M. Hermann-Turner and
Esther N. Benoit
Index
493
528
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Detailed Contents
Preface
About the Editors
About the Contributors
xv
xix
xx
CHAPTER 1 Working with Children, Adolescents,
and Their Parents: Practical Applications
of Developmental Theory
Ann Vernon and Pei-Chun Chen
Learning Objectives
A Developmental Model
Developmental Characteristics of Early Childhood
Developmental Characteristics of Middle Childhood
Developmental Characteristics of Early Adolescence
Developmental Characteristics of Mid-Adolescence
Take-Aways from Chapter 1
Helpful Websites
Practical Resources
References
1
1
3
7
12
17
23
29
30
30
30
CHAPTER 2 The Individual Counseling Process
Sarah I. Springer, Jean Sunde Peterson,
Lauren Moss, and Ann Vernon
Learning Objectives
Considerations for Working With Young Clients
Why Do Children and Adolescents Need Counseling?
Basic Counseling Skills
Other Words of Wisdom
The Counseling Process
Ethical and Legal Issues
Take-Aways From Chapter 2
Helpful Websites
Practical Resources
References
37
37
39
43
44
46
48
62
67
68
68
69
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CHAPTER 3
Creative Arts Interventions
Ann Vernon
Learning Objectives
Top 12 Reasons for Using Creative Arts
Play and Games
Therapeutic Writing
Music
Visual Arts
Literature
Drama
Take-Aways From Chapter 3
Helpful Websites
Practical Resources
References
CHAPTER 4 Play Therapy
Rebecca Dickinson and Terry Kottman
Learning Objectives
Appropriate Clients for Play Therapy
Goals of Play Therapy
Setting Up a Play Therapy Space
Basic Play Therapy Skills
Theoretical Approaches to Play Therapy
Multicultural Implications for Play Therapy
Working With Parents and Teachers
Training and Experience Required
for Play Therapists
Take-Aways From Chapter 4
Helpful Websites
Practical Resources
References
75
75
76
82
86
91
95
99
102
105
106
106
106
111
111
115
117
118
121
130
137
139
140
141
142
142
142
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CHAPTER 5 Solution-Focused Brief Counseling
Russell A. Sabella
Learning Objectives
What Is Solution-Focused Brief Counseling?
The Nature of the Counseling Relationship
Problem Assessment
The Individual Counseling Process
Five General Steps in SFBC
Four Ways to Move From Complaints and
Wishes to Goals
Three Criteria for Effective Solution-Focused Goals
Where Do I Start?
Refocusing From External to Internal
Involving All Stakeholders
Solution-Focused Parent Conferences
The PMS Approach to SFBC
Classroom and Small Group Applications
Take-Aways From Chapter 5
Helpful Websites
Practical Resources
References
CHAPTER 6 Reality Therapy
Robert E. Wubbolding
Learning Objectives
Choice Theory/Reality Therapy: A Universal System
Choice Theory—The Basis for Reality Therapy
Human Behavior—Through the Lens of Choice Theory
Perceptual System
Using Reality Therapy
The WDEP System of Reality Therapy
Reflecting the WDEP System
Reality Therapy and Diversity
Applications With Parents and Teachers
Using Reality Therapy in Groups
Reality Therapy in the Classroom
Take-Aways From Chapter 6
Helpful Websites
147
147
148
152
153
153
160
164
166
168
173
173
176
177
178
180
181
181
181
185
185
186
187
187
197
200
201
211
215
215
216
218
219
220
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Practical Resources
References
CHAPTER 7 Rational-Emotive Behavior Therapy
Ann Vernon
Learning Objectives
Rational-Emotive Behavior Therapy: An Overview
Rationale for Using REBT With Children and
Adolescents
Key Theoretical Concepts and Basic Principles
The A-B-C Model
The C.A.T. Model
Rational-Emotive Education (REE)
REBT Applications With Parents and Teachers
Take-Aways From Chapter 7
Helpful Websites
Practical Resources
References
220
220
222
222
223
225
227
232
234
244
251
254
254
255
255
CHAPTER 8 Counseling Children and Adolescents
With Exceptionalities
Tori Stone and Pamelia E. Brott
Learning Objectives
Introduction to Exceptionality
Students With Disabilities in Schools
Understanding Exceptionality
Counseling Children and Adolescents
With Exceptionalities
Theory-Based Interventions
Take-Aways From Chapter 8
Helpful Websites
Practical Resources
References
258
258
259
260
262
285
288
292
293
293
293
CHAPTER 9 Counseling Children and Adolescents
From Diverse Backgrounds
Darcie Davis-Gage
Learning Objectives
300
300
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A Diverse Nation
Examining Counselor Bias
Acculturation and Ethnic Identity Formation
Ethnically Diverse Children and Adolescents
Immigrants
Gender
Spirituality and Religion
Counseling Interventions With Diverse Youth
Take-Aways From Chapter 9
Helpful Websites
Practical Resources
References
CHAPTER 10
302
303
304
307
320
322
325
327
329
330
330
331
hildren and Challenges: Counseling from a
C
Growth Mind-set Perspective
Monica Leppma & Christine J. Schimmel
(with contributions by Anna Simmons)
Learning Objectives
Resilience
Protective Factors in Resilient Children
and Adolescents
Growth Mind-set vs. Fixed Mind-set
Counseling Children and Adolescents From
Various Types of Family Structures
Challenges Faced by Children and Adolescents
With Eating and Feeding Disorders
Challenges Faced by LGBTQIA+ Children and
Adolescents
Counseling Children Who Are Victims of
Bullying or Harassment
Counseling Grieving Children and Adolescents
Take-Aways From Chapter 10
Helpful Websites
Practical Resources
References
338
338
341
341
346
349
356
359
364
366
372
373
374
374
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CHAPTER 11
Counseling At-Risk Children and Adolescents
Jennifer E. Randall Reyes and Monica Leppma
380
Learning Objectives
Defining At-Risk Youth
Defining Adverse Childhood Experiences
Adverse Childhood Experiences and Developmental
Consequences
Systemic Societal Consequences That Contribute
to Trauma
Counseling At-Risk Children and Adolescents
With Trauma Symptoms
A Framework for Working With At-Risk
Children and Adolescents
Take-Aways From Chapter 11
Helpful Websites
Practical Resources
Programs
References
380
382
382
CHAPTER 12 Small Group Counseling
Christine J. Schimmel and Ed Jacobs
Learning Objectives
Reasons for Leading Groups With Children
and Adolescents
Stages of Groups
Common Issues in Leading Groups With Children
and Adolescents
Types of Groups for Children and Adolescents
Deciding What Groups to Offer
Group Formation
Essential Leadership Skills
Take-Aways From Chapter 12
Helpful Websites
Practical Resources
References
389
390
397
406
410
411
411
412
412
418
418
420
421
428
429
442
443
445
452
452
453
453
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CHAPTER 13 Working With Parents
Ann Vernon and Monica Leppma
Learning Objectives
The Challenges of Parenting
Parent Education and Consultation
Cultural Considerations in Working With Parents
Parent Education Programs
Organizing a Parent Education Program
Parent Consultation
General Parenting Information
Take-Aways From Chapter 13
Helpful Websites
Practical Resources
References
457
457
459
463
465
466
473
483
485
487
488
489
489
CHAPTER 14 Working With Families
Katherine M. Hermann-Turner and
Esther N. Benoit
Learning Objectives
Why Focus on the Family?
Family Counseling
Application of a Systemic Perspective
Family Theory
The Therapeutic Process
Family Counseling in Schools
Special Considerations in Working With Families
Take-Aways From Chapter 14
Helpful Websites
Practical Resources
References
Index
493
493
495
496
499
501
509
516
520
523
524
525
525
528
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Preface
C
hildhood has changed dramatically over the years, and for many children,
it is no longer the carefree period of life where engaging in activities such as
capturing fireflies in a jar, soaring high on a tire swing, or playing hide and
seek are everyday experiences. These simple pleasures were inexpensive, creative, and
healthy—in sharp contrast to what many of today’s youth do for fun. While many
children and adolescents continue to be enamored by DVDs or video games, the Internet is their go-to source of entertainment and is primarily accessed through mobile
devices such as iPads, iPhones, and tablets for the purpose of gaming and watching
YouTube videos. Social networking sites have replaced many of the play and social
skill-building activities that are such an important part of a child’s development.
For many youth, childhood used to be a time where they were nurtured and
protected and were essentially free from responsibilities. But, to a large extent, that
has changed, and in so many ways the world is more complex than ever before.
When I (Ann) wrote the preface for the previous edition of this book, I noted that
children and adolescents were faced with many challenges; that, in addition to
normal growing-up problems, young people had to deal with the complexities of
our contemporary society. The same holds true today—but to a much greater degree.
Now, children seem to have lost their innocence and have to contend with issues
far beyond their level of comprehension. They grow up too fast and too soon, and
although they may be young chronologically, they are exposed to adult issues through
the media and the Internet, as well as through day-to-day experiences that they are
not developmentally equipped to deal with. Now, in addition to helping children
and adolescents deal with serious issues such as addiction, eating disorders, abuse,
and non-suicidal self-injury, counseling professionals struggle to help young people
cope with cyberbullying that occurs long after the school day has ended, the possibility of coming in contact with sexual predators online, and even the reality of a
child human trafficking epidemic. Even adults are frequently at a loss as to how to
deal with the stressors that characterize this rapidly changing society, so it stands
to reason that children experience even greater stress, which is oftentimes expressed
behaviorally because they cannot articulate how they feel. Although we would like to
think that children are immune to these stressors, the sad reality is that we cannot
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protect them from poverty, violence, intolerance, and hate. Try as we might, we
cannot always shield them from abuse and neglect or parents who are ill-equipped
to nurture and provide for their children because they are dealing with their own
issues such as addiction, incarceration, or some form of mental illness. While most
parents want to do the best for their children, their circumstances might impact
their ability to do so.
In addition, children and adolescents are now more fearful and feel more vulnerable
as a result of the increasing violence in their schools and communities, as well as the
threat of terrorism. Imagine being a student in a school when a gunman, possibly a
fellow student, unleashes a string of bullets that kills his or her teacher and many of
his or her classmates. Innocent young people shouldn’t have to experience this kind
of chaos, fear, and trauma that will not only impact their development, but also their
lives for years to come. How do we adults help them deal with the significant ramifications of these terrifying events when we struggle make sense of them ourselves?
In reality, there are many barriers in today’s society that impede children and
adolescents’ ability to grow up without giving up. Throughout the world, many children live in poverty, have no access to health care, or live in dysfunctional families
where boundaries are blurred and children are forced to assume caretaker roles
and adult responsibilities. Young people have no control over whether their parent
or parents are deployed to fight for their country or whether they or their parents
will be deported because they are illegal immigrants. In essence, they are vulnerable, and, for the most part, are dependent on the adults in their environment for
support and guidance. If these adults cannot or do not assume this responsibility,
children are at far greater risk and are susceptible to the numerous societal changes
that affect their well-being.
Clearly, school and mental health professionals must assume an important role
in helping young people deal with the challenges of growing up. We must find
effective ways to teach them how to be resilient and equip them with tools to handle
the typical developmental problems as well as the more serious problems that so
many will encounter. By listening to their stories, employing effective interventions,
advocating for them, and informing parents and other professionals about child
and adolescent development and other important issues, we can help make their
journey through life easier.
Children are our future—and in this world where values are changing and societal norms are rapidly fluctuating, helping professionals need to actively intervene
with caregivers since the home environment is so central to a child’s development.
Despite the fact that family constellations are changing, what hasn’t changed is the
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importance of a stable home environment that can provide children with love, support, and adequate care. Although schools and communities also play a major role
in assuring the healthy development of youth, it is in the home where children are
socialized to their race, ethnicity, religion, gender roles, beliefs, and values. Without
adequate adult guidance and healthy role models, we can expect to see an increase
in social-emotional and behavioral problems, as well as learning difficulties. In
order to protect our future in this global society, we, as counseling practitioners,
must take a leadership role to implement strategies that promote the well-being of
children, adolescents, and their families and caregivers.
ABOUT THIS EDITION
The fifth edition of this book has been revised in several significant ways. First, most
of the authors and all the co-authors are new. Second, each chapter begins with a
case-study vignette, which will also be referred to at the end of the chapter, where
the authors share what they learned from working with a young client or family
and what techniques they used that they considered most effective. In addition
to the vignette at the beginning of the chapter, there are case studies, numerous
interventions, counselor-client dialogues, and examples of group/classroom activities
interspersed throughout each chapter to illustrate application of key principles. In
this edition, there are also sidebars that include several distinctive features:
a.
Dialogue Box. This sidebar is a verbatim short exchange between a client and
a counselor to illustrate how to deal with a specific problem or initiate an
interaction with a young client, relative to the content of the chapter.
b.
Voices from the Field—Professional. In this sidebar, a counseling practitioner
shares a piece of advice or an opinion or something he or she has applied with
clients related to the chapter content.
c.
Now Try This! This sidebar describes a short exercise or intervention that readers
can try to help them apply what they have read in the chapter.
d.
Voices from the Field—Child or Adolescent. In this sidebar, a young client shares
his or her perspective or experience in individual or small group counseling.
e.
Personal Reflection. This sidebar directs readers to personally reflect on one or
more specific questions relative to the chapter content.
f.
Add This to Your Toolbox! This sidebar describes a specific technique relative
to the chapter content that the authors have found to be especially effective.
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This revised edition highlights the importance of taking young clients’ level of
development and culture into account throughout the counseling process. These two
factors are discussed in stand-alone chapters and are emphasized throughout the
book. In addition, there are chapters on reality therapy, rational-emotive behavior
therapy, play therapy, and solution-focused brief counseling, which are considered
the most effective approaches to use with young clients. Other chapters present
relevant information about the counseling process as it specifically applies to young
clients, creative counseling interventions, counseling children with exceptionalities,
working with families, and counseling young clients in small groups. In addition,
given the increased challenges today’s youth are experiencing, we included a chapter on at-risk youth and another on working with children and adolescents from a
growth mind-set perspective, which describes how to help children and adolescents
develop resiliency.
Readers of previous editions have told us time and time again how much they love
the practicality of this text and the numerous engaging examples that enhance the
content of the book. The importance of keeping with this tradition was stressed to the
authors as they wrote their chapters. These authors are all well-respected authorities
in their field and have provided pertinent, practical, and up-to-date information that
will increase readers’ knowledge about effective counseling strategies for children and
adolescents in an ever-changing and challenging global society. We hope that this
fifth edition will be a valuable resource that students and counseling practitioners
will use to help make a difference for today’s children and families.
—Ann Vernon and Christine Schimmel
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About the Editors
ANN VERNON, PH.D., is professor emerita at the University of Northern Iowa
where she coordinated the school and mental health counseling programs for many
years. In addition, she had a large private practice, specializing in counseling children,
adolescents, and their parents. Dr. Vernon has written over 25 books, as well as many
invited book chapters and refereed journal articles. These publications, including
What Works When with Children and Adolescents and the Thinking, Feeling, Behaving
emotional education curriculums, focus on practical interventions that help enhance
young people’s social/emotional development. Dr. Vernon has held various leadership positions in professional counseling organizations, founded the ACES women’s
retreats, is an ACA fellow, and was the second person to be awarded diplomate status
through the Albert Ellis Institute. Dr. Vernon, a former school counselor, conducts
workshops and in-depth trainings on topics related to her areas of expertise: parenting,
developmental considerations in counseling children and adolescents, interventions
for internalizing disorders, creative counseling techniques, and counseling couples.
Currently, she trains counseling practitioners in various parts of the world to apply
rational-emotive behavior therapy with children and adolescents, as well as with
adults. She is the president of the Albert Ellis Institute and is considered the leading
international expert in applications of REBT with children and adolescents.
CHRISTINE J. SCHIMMEL, ED.D., LPC, is an associate professor in the Department
of Counseling, Rehabilitation Counseling, and Counseling Psychology at West Virginia
University. Dr. Schimmel coordinates the school counseling program and specifically
focuses on working with and training school counselors. Prior to becoming a counselor educator, she was a school counselor. Dr. Schimmel has devoted over 20 years to
providing staff development and workshops on topics relevant to both clinical mental
health and school counselors. She has presented on topics such as impact therapy, creative counseling techniques, counseling theory, dealing with challenging students, and
group counseling. Dr. Schimmel has published more than 10 articles, book chapters,
and monographs on these subjects as well. Along with her colleague, Dr. Ed Jacobs,
they have published one of the most widely used group counseling textbooks on the
market, Group Counseling: Strategies and Skills, which is now in its eighth edition.
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About the Contributors
ESTHER N. BENOIT, PH.D., LPC, received her M.Ed. degree in marriage and family
counseling and her Ph.D. in counselor education from the College of William and
Mary in Williamsburg, Virginia. Dr. Benoit currently serves as a faculty member in
the clinical mental health program at Southern New Hampshire University and is
actively involved in identifying and supporting the needs of families and individuals in the greater Hampton Roads community. Prior to taking the position in New
Hampshire, she worked as a family, couples, and individual counselor in Virginia,
where she continues to work with at-risk youth and their parents through a grantbased prevention program in both group and family counseling settings.
PAMELIA E. BROTT, PH.D., LPC, has over 20 years of experience as a counselor
educator and 14 years of experience as a school counselor. Currently, she is an associate professor and coordinator of the school counseling program at the University
of Tennessee, Knoxville. She is the author of 38 publications and 39 international
and national conference presentations that span the fields of school counseling and
career counseling. She is co-author of the book What School Counselors Need to
Know about Special Education and Students with Disabilities. Her areas of interest in
school counseling are accountability, practical action research, career development,
and professional school counselor identity development.
PEI-CHUN (OLIVIA) CHEN, PH.D, is an assistant professor of counseling at the Univer-
sity of Northern Iowa. She received her doctorate degree from the University of Florida.
Her primary research interests center on multicultural counseling and supervision.
She is currently developing a multicultural counseling self-efficacy scale for counselors
working in Confucian and collective cultures. Dr. Chen’s teaching includes courses in
intervention and prevention through the developmental lifespan, family counseling,
counseling skills, and developing comprehensive school counseling programs.
DARCIE DAVIS-GAGE, PH.D., is the division chair and program coordinator of
counseling, clinical coordinator of mental health counseling, and CACREP liaison
at the University of Northern Iowa where she has been a faculty member since 2005.
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Her teaching interests are in the areas of group process, multicultural counseling,
career counseling, and mental health specialty courses. She brings 20 years of various
counseling experiences to the classroom. Dr. Davis-Gage has worked as a counselor
in a variety of mental health agencies, which include a partial hospitalization program, a women’s mental health agency, a college counseling and advising center,
and private practice.
REBECCA DICKINSON is a social work Ph.D. candidate at the University of Iowa.
She is currently completing her dissertation on the topic of using Adlerian play
therapy with children who have experienced trauma. She is employed in the community as a play therapist, working primarily with foster/adoptive children, as
well as providing therapy services in local elementary schools. In addition to play
therapy-related topics, she has presented and published on a variety of social work
topics, including best practices in social work field education, ethical issues in taking
social work students abroad in immersion programs, and social justice issues related
to children with disabilities.
ED JACOBS, PH.D., LPC, is the coordinator of the master’s program in counseling
at West Virginia University and the founder of impact therapy. He is a well-known
presenter at the national and international level (over 400 workshops) and the author
of six books, including three on group counseling. Dr. Jacobs’s areas of expertise
include creative counseling, group counseling, counseling techniques, and counseling
theory. Dr. Jacobs’s presentations are extremely popular due the practical nature of
his approach. His co-authored book, Group Counseling: Strategies and Skills, is now
in its eighth edition. Dr. Jacobs is an ASGW (Association for Specialists in Group
Work) fellow.
TERRY KOTTMAN, PH.D., NCC, RPT-S, LMHC, founded the Encouragement
Zone, where she provides play therapy training and supervision, life coaching,
counseling, and “playshops” for women. Dr. Kottman developed Adlerian play
therapy, an approach to working with children, families, and adults that combines
the ideas and techniques of individual psychology and play therapy. Dr. Kottman
is the author of many publications, including Play Therapy: Basics and Beyond, and
is the co-author (with Dr. Kristin Meany-Walen) of Partners in Play: An Adlerian
Approach to Play Therapy (3rd ed.). She is the recipient of the Lifetime Achievement
award from the Association for Play Therapy and the Lifetime Achievement award
from the Iowa Association for Play Therapy.
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MONICA LEPPMA, PH.D., LMHC, is an associate professor of counseling (clinical
mental health and school counseling emphasis) at West Virginia University. She
earned her doctorate in counselor education from the University of Central Florida.
Dr. Leppma is a licensed mental health counselor experienced in working with children, adolescents, and adults in a variety of clinical settings. Her research focuses on
counselor development and protective factors for children and adults. Dr. Leppma
has authored or co-authored a number of peer-reviewed articles in these areas.
LAUREN MOSS, PH.D., LPC, is an assistant professor at Kutztown University in
the department of counselor education where she serves as the co-coordinator of the
school counseling program. Dr. Moss has extensive experience in the public school
setting at the middle school level, both as a professional school counselor and special educator. Her professional experiences working with diverse populations have
led her to research interests in group work, bullying prevention, social justice, and
advocacy. Dr. Moss prides herself in working as a change agent, particularly in the
school setting, to support and advocate for/with all clients. She has published many
journal articles and book chapters on these topics.
JEAN SUNDE PETERSON, PH.D., professor emerita at Purdue University, directed
the school counseling program, which was the NBCC Program Professional Identity awardee in 2011. Dr. Peterson continues to work clinically in retirement. Her
extensive publication record includes books, refereed journal articles, and invited
chapters that focus on the social and emotional development of high-ability youth
and the bridge between gifted education and counseling fields. Her most recent book
is Counseling Gifted Students: A Guide for School Counselors (with Dr. Susannah
Wood). She is the recipient of 10 national awards and 12 from Purdue University for
research, teaching, or service. Her first career was in K–12 education.
JENNIFER E. RANDALL REYES, PH.D., LPC, is currently an associate professor
in the Department of Psychology, Human Development, and Counseling at Prescott
College. Her dissertation, The Lived Experience of Mental Health Providers in Adventure Therapy Programs received the SEER award for valuable research contributions
to the field. Her consultation and research efforts are geared toward creating effective systems of care for the most vulnerable of populations. For the past 15 years,
Dr. Randall’s primary area of clinical focus has been working with at-risk youth
and their families. Her work has spanned the foster care system, juvenile justice,
private and public residential out-of-home placements, and now private practice.
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RUSSELL A. SABELLA, PH.D., is currently a professor in the Department of Coun-
seling in the College of Health Professions and Social Work at Florida Gulf Coast
University, and he is president of Sabella & Associates. Dr. Sabella is the author of
numerous articles and the co-author of three books. He is also the author of the
popular SchoolCounselor.com: A Friendly and Practical Guide to the World Wide Web
and GuardingKids.com: A Practical Guide to Keeping Kids out of High-Tech Trouble.
Dr. Sabella is well-known for his “Technology and Data Boot Camp for Counselor”
workshops conducted throughout the country. He is past president of the American
School Counselor Association and the Florida School Counselor Association.
SARAH I. SPRINGER, PH.D., LPC, is currently an assistant professor in the Clinical Mental Health Counseling program at Monmouth University. She is a licensed
professional counselor in private practice and an educational consultant in the New
Jersey public schools. Formally, Dr. Springer practiced as a school counselor and
was trained as a music educator, working with students across the K–12 grade levels.
Dr. Springer has published on group counseling, supervision, and topics specific to
the work of school counselors. She, along with several colleagues, recently published A
School Counselor’s Guide to Small Groups: Coordination, Leadership, and Assessment.
TORI STONE, PH.D., LPC, is an assistant professor of education in the Counsel-
ing and Development program at George Mason University in Fairfax, Virginia.
Prior to becoming a full-time counselor educator, Dr. Stone worked as a school
counselor in Virginia for 17 years. Dr. Stone’s interests include creative counseling
and providing professional development in best practices for school counseling
site supervisors. She is passionate about counseling children and adolescents and
training future counselors.
KATHERINE M. HERMANN-TURNER, PH.D., is an assistant professor in the
Department of Counselor Education at the University of Louisiana at Lafayette.
She received her doctoral degree in counselor education and supervision with a
specialization in marriage and family counseling from the College of William &
Mary. Dr. Hermann-Turner holds an endowed professorship in education at the
University of Louisiana at Lafayette. She is an active counselor educator engaging
in scholarship and service at the university and national level. Dr. Hermann-Turner
currently holds leadership roles with the Association for Adult Development and
Aging (AADA) and service roles on several editorial boards.
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ROBERT E. WUBBOLDING, ED.D., LPCC, BCC, is a psychologist, counselor,
and director of the Center for Reality Therapy in Cincinnati, Ohio, and is professor
emeritus at Xavier University. Dr. Wubbolding served as the director of training for
the William Glasser Institute from 1988–2011. He has authored 17 books on reality
therapy, as well as 150 articles and essays and 37 book chapters. His book Reality
Therapy and Self Evaluation: The Key for Client Change is the most comprehensive
book on the theory and practice of reality therapy. Bob has taught reality therapy
in Europe, Asia, the Middle East, North Africa, and North America.
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CHAPTER 1
Working with Children,
Adolescents, and Their Parents
Practical Applications of Developmental Theory
Ann Vernon and Pei-Chun Chen
LEARNING OBJECTIVES
1.
To understand how development impacts the way children and adolescents
respond to typical developmental problems as well as to more serious situational issues
2.
To describe specific developmental characteristics for early and middle childhood and early and mid-adolescence
3.
To identify examples of developmentally appropriate interventions for early
and middle childhood and early and mid-adolescence, as described through
case studies
I
(Ann) received a phone call from Mrs. Jacobs who requested an appointment with
me to discuss concerns about her 18-year-old daughter Megan, a senior in high
school. She shared that Megan had always been a good student and had been very
involved in several leadership and extracurricular school activities throughout high
school. However, this year she had decided not to participate in marching band or
cheerleading, which she had loved, and she had also withdrawn from many of her
friends. According to Mrs. Jacobs, there were other changes as well, which made her
suspect that her daughter might be depressed, although Megan denied it and said
she did not need counseling. Nevertheless, Mrs. Jacobs expressed a desire to meet
with me to discuss her observations in greater detail.
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During the first meeting, Mrs. Jacobs shared that Megan, an only child, had
always been a “good girl” and had been open with both parents. However, during
the past several months, both she and her husband noticed that Megan was not as
forthcoming. Another change that Mrs. Jacobs had noticed was that her daughter
was buying clothes from a secondhand store and she was embarrassed about her
daughter’s appearance, especially when they were together in public. And, although
she still had a good grade-point average, Megan wasn’t studying as much as she
used to.
I shared a list of symptoms of depression with Mrs. Jacobs, asking her to identify
those that she had observed with Megan. Other than being more withdrawn at home
and not as active in school activities as in previous years, she didn’t think the other
symptoms applied to Megan. She couldn’t pinpoint it exactly, but said that Megan
just appeared to be changing. I reassured her that she had done the right thing by
making this appointment and asked her to see if Megan would be willing to attend
a session so that I could better understand the situation.
Given that Megan had told her mother that she didn’t need counseling, I was
surprised that she agreed to come in. I was expecting her to be resistant, but she was
actually very open and engaged throughout the session. With her mother’s permission, I shared the parents’ concerns and asked Megan for her reaction. She said that
she was not depressed and thought her mother was using that as an explanation for
the fact that she no longer had any interest in the school activities that her mother
wanted her to be involved in. Megan also shared that her subjects weren’t all that
challenging and she was ready to be finished with high school and get away from the
superficial and immature people with whom she had very little in common. Because
her birthday was in November, she was older than many of her high school peers, and
she said it was more meaningful to associate with several students who had graduated
the previous year and were attending a local community college. She knew that her
parents, especially her mother, would not approve of these new friends who didn’t
wear “preppy” clothes to impress, which is what her mother wanted her to do. She
expressed frustration that her mother wanted to bend and shape her into what she
wanted Megan to be like, when in fact Megan was searching for herself and wanted
to be her own person.
After listening to Megan, it seemed clear that she was probably more mature than
most of her peers and was pondering and philosophizing about issues, as well as
questioning her values. I explained to Megan that this was very normal, part of the
“search for self” that occurs during this stage of development. Although I saw no
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outward signs of depression, I did give her a depression inventory, which confirmed
what I had suspected—this was not about depression, but rather, it was about growing
up, achieving independence, and developing her own identity.
As this vignette illustrates, knowledge about developmental characteristics is
essential in assessment and intervention with children, adolescents, and their parents.
Without this perspective, problems can easily be misconstrued. As was the case in
this vignette, parents may assume that the symptoms they see are more pervasive if
they fail to take into account what is normal for each stage of development.
The purpose of this chapter is to describe applications in counseling and consulting for early childhood, middle childhood, early adolescence, and mid-adolescence.
Typical characteristics are described for these children, ages 4 to 18, in five areas
of development: self, social, emotional, cognitive, and physical. Case studies will
illustrate typical developmental problems, assessments, and interventions.
A DEVELOPMENTAL MODEL
It is important to understand how children’s level of development influences how
they respond to their attainment of basic needs, as well as to normal developmental
issues and more significant situational problems. The model in Figure 1.1 illustrates
this more specifically. In the center of the triangle are basic needs that, according
to Maslow (1968), all humans have: physiological needs (food and shelter), safety
needs (personal and psychological), love and belonging (feeling accepted), self-esteem
(feeling good about self), and self-actualization (fulfilling potential). When these
basic needs are not met, children respond to the deficits depending on their developmental level in one or more of the areas listed in the next level: self, emotional,
social, cognitive, and physical.
Thus, young children in the preoperational stage of cognitive development
will respond very differently to a basic need for safety than will adolescents who
have begun to develop abstract thinking skills. Young children do not have the
ability to clearly identify or express their feelings, nor do they understand all
the ramifications of the situation or have the ability to generate effective coping
strategies. For example, young children might experience fear but not know what
to do about it if someone breaks into their home, whereas an adolescent might
be better able to assess the threat and figure out a safety plan. The implication,
therefore, is that the experience itself is mediated by the level of development and
impacts children accordingly.
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Developing serious
mental health problems
Suicide
Peer
relationships
Transitions
Independence/
autonomy
Pov
ert
y
Sel
f
Em
otio
nal
Social
Addictive
behaviors
Delinquency
Eating
disorders
S
Ho
m
e
iction
l add
enta
Par
Physical, se
x
u
a
l, em
otio
n
a
la
bu
se
Sexual
acting out
Athletic/
musical
performance
Deportatio
n
al
Gender
identity
Self-actualization
Self-esteem
Love and belonging
Safety needs
Physiological needs
School
performance
sic
Phy
Sexuality
ill
ess
sn
les
Being bu
llied
Sexual
orientation
Dropping out
of school
Dating
tive
gni
Mastery/
competition
violence
estic
dom
d
l an
oo
ch
Belonging/
rejection
Ch
ron
ic
s
t attack
roris
Ter
Div
orc
e
Al
Relationships
with parents
Co
Gang
involvement
e
tiv
na
ter
Caregiver incar
cera
ted
ath
de
ss/
ne
Nonsuicidal
self-injury
tures
truc
ily s
m
fa
At-risk
behaviors
Teen pregnancy
FIGURE 1.1 Developmental model.
The level of development also influences how children respond to the normal
developmental problems that most children and adolescents throughout the world
experience in some degree of another and are listed in the first circle of the model:
relationships with peers and parents, school performance, belonging and rejection,
transitions such as graduating, and so forth. Once again, how they respond to these
typical issues depends on their level of development. The “Dialogue Box” sidebar
illustrates how self-conscious teens, whose abstract thinking skills are limited, lack
the ability to generate good solutions to problems.
The same applies to how children respond to the more serious situational problems listed in the next circle: being the victim of abuse, experiencing school and/or
domestic violence, living with a chronic illness or experiencing the death of a close
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DIALOGUE BOX
COUNSELOR: “Jason, I understand that you and some of your friends
have been skipping some classes. Your teachers are concerned.
Would you be willing to tell me more about this?”
CLIENT: “Well, we hate speech class. It’s so embarrassing to get up
in front of other kids and have to give a speech.”
COUNSELOR: “I get it. You’re afraid you’ll make some mistakes and
everyone will notice, right?”
CLIENT: “Yeah … and they might laugh.”
COUNSELOR: “And maybe they’d notice if you had a pimple or if
your hair didn’t look just right?”
CLIENT: “Yeah … .”
COUNSELOR: “You may not know this, but it’s pretty typical for
kids your age to feel embarrassed like this, and I bet you are also
skipping physical education because you don’t want to undress in
front of others. But do you think that skipping these classes is really
the answer since it has gotten you in trouble? Can you think of any
other ways to handle this problem?”
family member, being deported, living with divorced or alcoholic parents, and so
forth. Fortunately, these are problems that not all children experience, although
increasingly these situational problems are becoming more prevalent. How young
clients respond to these issues also depends, again, on their developmental level.
For example, a 7-year-old whose mother abandoned the family will have difficulty
understanding how her mother could do this if she loves her daughter. The 7-yearold’s thinking is concrete and dichotomous: Her mother loves her and stays with the
family or she doesn’t love her and she leaves. A 17-year-old whose cognitive skills
are more advanced would be able to recognize other relevant factors and issues that
influenced her mother’s decision and would not automatically assume that because
her mother left the family she doesn’t love her daughter.
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Finally, how children interpret and respond to basic needs, as well as to typical
and situational problems, can result in various self-defeating behaviors, as listed
around the outside edges of the circles: becoming pregnant, dropping out of school,
developing problems with eating disorders or drugs/alcohol, or engaging in other
at-risk behaviors. These problems are much more difficult to treat and have significant negative consequences that can impact the lives of children and adolescents
for years to come. The following vignette illustrates this concept:
Sophia was 10 when her dad lost his job. Although money was tight, they managed
to live on what her mother made as a house cleaner until she fell and broke her arm
and was not able to work for several months. Since there wasn’t enough money to
pay the rent, the family was homeless for several months. There were many nights
that Sophia could not sleep because she was cold, hungry, and frightened. Even
though her parents usually made sure she went to school, she was embarrassed to
go because she was often dirty and disheveled and feared being teased and taunted
by her peers, which happened repeatedly. Sophia kept her feelings to herself, but as
the humiliation increased, her self-worth plummeted; she believed she was as ugly
and worthless as her classmates claimed.
Eventually Sophia’s father was able to secure a new job, and once again they were
able to move into an apartment. Although she was no longer cold and hungry,
Sophia’s situation at school did not change. She lacked both the confidence and
social skills that she needed to be accepted by peers. She began to develop physically
and suddenly became the center of attention because boys were very attracted to
her. For the first time, she felt like she belonged. Before long, she became sexually
active, which was her way to feel loved and respected. Unfortunately, her physical
maturity was not accompanied by maturity in other areas of development. She
illogically attributed her popularity with boys as the way to feel worthwhile, lacked
the social skills to assertively deal with the pressure to have sex, and didn’t think
about the consequences of being sexually active. Consequently, by the time she was
15 she was pregnant and had dropped out of school.
As this vignette illustrates, the way children process experiences, as depicted in
Figure 1.1, is influenced by their developmental maturity. Helping professionals need
to recognize this reality and take an active role in helping their clients develop the
emotional, social, cognitive, and self-development skills they need to handle the
normal, as well as the situational, challenges of growing up so that they don’t resort
to self-defeating ways to deal with problems that result in more major issues. Also,
it is extremely important to consider developmental, as well as cultural, factors in
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problem conceptualization, in designing or selecting age-appropriate assessment
instruments, and in developing interventions.
DEVELOPMENTAL CHARACTERISTICS
OF EARLY CHILDHOOD
Although early childhood is from ages 2 to 5, it is beyond the scope of this chapter
to deal with this entire age range. Thus, the focus will be on 4- and 5-year-olds.
Because traditional talk therapy is generally not effective for this age group (Leggett, Roaten, & Ybanez-Llorente, 2016), counselors must use a variety of concrete
approaches such as various forms of play media that include games and puppets,
as well as art and music activities, and other interventions, which are described in
chapter 3. Keeping in mind that young children’s ability to respond to counseling
interventions depends on their developmental level, the following information on
developmental characteristics of young children is provided.
SELF-DEVELOPMENT
Preschoolers are egocentric—assuming that everyone thinks and feels as they do.
They have difficulty seeing things from another’s perspective. This egocentrism
is reflected in their excessive use of “my” and “mine.” They have relatively high
self-esteem and unrealistically positive self-views. Because they are just beginning
to form a more balanced self-evaluation that also incorporates external feedback
and social comparisons (Robins & Trzesniewski, 2005), they think that they are
competent in everything (Orth & Robins, 2014). This belief is advantageous at this
stage when they have so many new tasks to master. With each mastery, their sense
of competence increases, and when they enter preschool, they demonstrate more
initiative as they face more challenges and assume new responsibilities.
Another self-development issue relates to preschoolers’ self-control, which increases
during this period. They are better at modifying and controlling their impulses and
are not as frustrated and intolerant if their needs are not met immediately (Duckworth & Steinberg, 2015).
SOCIAL DEVELOPMENT
Play serves an extremely important function for children at this age. Most of the
play for 4-year-olds is associative; they interact and share, and although they
are engaging in a common activity, they do not assign roles nor cooperate easily
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(Broderick & Blewitt, 2014). By age 5 they begin to engage in more cooperative
play: taking turns, creating games, sharing, dealing with conflict, and attaining
a common goal (Coplan & Arbeau, 2009). They also engage in more structured
games that are based on reality, according to Lillard, Pinkham, and Smith (2011).
Children at this age do not understand give and take, and due to their egocentricity,
they are typically unable to see another child’s point of view. Because they also have
difficulty understanding intentionality, they may misinterpret others’ behavior and
respond inappropriately. After 4 years of age, their increased ability in perspective
taking promotes the formation of friendships (Slentz & Krogh, 2017).
Gender differences are quite apparent at this stage. As early as the age of 3,
children prefer same-gender playmates (Newman & Newman, 2017), and the
preference appears to be culturally universal, according to Munroe and Romney
(2006). They also demonstrate gender-based preferences in choice of toys and types
of play, as boys more readily engage in rough, noisy, competitive and aggressive
play, whereas girls are more nurturing and cooperative (Hanish & Fabes, 2014;
Slentz & Krogh, 2017).
EMOTIONAL DEVELOPMENT
Although their vocabularies are expanding and they are beginning to understand
which emotions are appropriate to specific situations, preschoolers still have a rather
limited vocabulary for expressing how they feel (Berk, 2017). As a result, they often
express their feelings behaviorally. According to Berk (2017), children at this age
have difficulty understanding that they can experience different emotions about a
situation simultaneously, although they can understand the concept of experiencing
different emotions at different times. They are still quite literal and cannot clearly
differentiate between what someone is expressing overtly with what they may be
feeling (Broderick & Blewitt, 2014).
Toward the end of the preschool period, children have a better understanding of
why others are upset, and they begin to respond verbally or physically to others’
emotions. Their understanding of other people’s emotions is limited, however, by
their perception, and they tend to perceive only the most obvious aspects of an
emotional situation, such as being mad, happy, or sad (Broderick & Blewitt, 2014).
Gender differences in emotional expression are quite apparent at this age. Girls
express more internalizing emotions, such as sadness, whereas boys show greater
externalizing emotional expressions, such as anger (Chaplin & Aldao, 2013).
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COGNITIVE DEVELOPMENT
To 4- and 5-year-old preschoolers, the world is a fascinating place. With their imaginations and vivid fantasies, anything is possible. Ordinary playrooms become
transformed into museums, and imaginary friends are frequent dinner-table guests.
Typical preschoolers are curious, energetic, eager, and fascinating to be around.
The cognitive development of preschoolers is characterized by preoperational
thinking (Fernandez, 2014). Although preschoolers are beginning to reason more
logically if they are asked to think about familiar things in a familiar context, they
still rely heavily on solving a problem based on what they hear or see rather than
by logical reasoning. According to Gopnik (2012), preschoolers can think more
scientifically than Piaget suggested, such as inferring abstract physical causal laws
(Schulz, Goodman, Tenenbaum, & Jenkins, 2008) or making appropriate inferences
when they listen to a story. They have difficulty with abstract concepts such as death
and divorce (Berk, 2017).
Also characteristic of their cognitive style is the tendency to center on their perceptions or on one aspect of the situation, rather than on a broader view (Case, 2013).
This style of thinking interferes with their ability to understand cause and effect
and to see that the same object or situation can have two identities. For example,
they may be unable to grasp the concept that their teacher could also be a parent.
They are also quite literal. For example, I remember when my (Ann’s) son was in
preschool and announced one day that the family friend who walked him from
school to day care couldn’t do it anymore because she was a stranger. Even though
she wasn’t technically a stranger, he hadn’t known her for long and misinterpreted
what the fireman meant during a discussion about strangers and dangers.
Two additional characteristics of preschoolers’ thinking are animism and artificialism (Rathus, 2004). Animism refers to the attribution of lifelike qualities to
inanimate objects, such as comforting a doll when it falls. Artificialism is the belief
that people cause natural phenomena, such as thinking that rain occurs because
fire fighters are spraying water from the sky. Both these characteristics contribute
to their ability to engage in make-believe play.
Another important facet of cognitive development during this period is language. By age 5, they can understand most things explained to them in daily life
if the examples are specific (Slentz & Krogh, 2017). Although they can understand
relationships between the past and the future (Lillard et al., 2011), they still struggle
with time and space, as characterized by the frequent question, “Are we there yet?”
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PHYSICAL DEVELOPMENT
Young children seem to be in perpetual motion as they explore their world and
focus their energy on a variety of things. Although physical growth is slower
during the preschool years than in earlier years, gross motor skills, such as locomotion, object control, and stability, improve dramatically during this period
(Broderick, 2010).
Fine motor skills develop more slowly, but also improve significantly during
early childhood. Drawing, writing, and using scissors are more difficult to master
because they involve small body movements, but nevertheless, 4-year-olds can cut
with scissors, copy simple shapes and reproduce letters, and by age 5 children can tie
their shoes and zip their coats (Slentz & Krogh, 2017). Although their muscles have
increased in size and strength, children at this level still have immature functioning
compared to children in middle childhood.
Case Study—Early Childhood
Lydia ‘s parents sought counseling for their 5-year-old daughter shortly after the
birth of her baby brother. Prior to his birth, Lydia was very excited about having
a new sibling, but after he was born and Lydia realized that she was no longer
the center of attention, she began expressing her feelings by throwing tantrums,
atypical behavior for her, and being very defiant. Both parents said that they had
tried to spend quality time with their daughter, but the baby had colic and only
slept for short periods of time, so things were very stressful at home. While they
understood that this was a major adjustment for Lydia, they were sleep-deprived
and would lose their temper with her, which only compounded the problem.
At the first visit, I (Ann) engaged Lydia in a short get-acquainted activity, “Button, Button” (Vernon, 2009), to put her more at ease since this was her first experience with a counselor. We took turns guessing in which hand a button was hidden,
and when we made a correct guess we drew a card from a pile and completed an
unfinished sentence, such as “something I wish I could do,” “something I get mad
about,” “something I don’t like.” This short intervention was helpful because Lydia’s responses reflected her thoughts and feelings about the changes in her family.
I followed the get-acquainted activity by reading I’m a Big Sister (Cole, 2010)
and we discussed the similarities between the characters in the story and her situation with her baby brother. I then asked her to show me with the play family dolls
how things had changed in her house since her brother had been born. Based
on what the parents had shared, Lydia’s portrayal of the situation appeared to be
very accurate.
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During the next session, I engaged Lydia in a role play, where I was the mother
who was trying to quiet a crying baby and Lydia was trying to get her mother’s
attention because she wanted something to eat. Lydia threw a little tantrum and
yelled at me, saying she wanted to run away because I never paid any attention
to her. After the role play, I asked Lydia to raise her hand if either her mom or dad
had done any of the following with her this past week: helped her take a bath and
brush her teeth, fixed her lunch, read her a story, or tucked her into bed. I pointed out that since she had raised her hand every time, could she actually say that
her mom and dad never did anything for her or never paid attention to her? She
understood my point and we generated a list of other ways that her parents show
her that they care about her. I gave her the list and she suggested that she draw
pictures to represent what was on the list and look at it when she started to think
that her parents didn’t pay attention to her or take care of her.
During this session, we also focused on her feelings by playing a feeling game.
She identified that she felt jealous, mad, sad, and scared. After discussing these
feelings more in depth, I suggested that during the next session we make a book
expressing how she felt about having to share her parents with her brother, and, if
she wished, she could read the story to her parents.
After we finished the book at the beginning of the next session, with her dictating the dialogue to me and then illustrating it, we moved to another intervention.
I had asked her parents to bring a scrapbook of Lydia as a baby, so we looked
through it, noting the similarities between how her parents treated her as a baby
and how they were treating her baby brother. This review seemed to help her
understand that her parents had given her the same amount of attention when
she was a newborn, but she said she still felt bad when her brother got so much
attention now and said it was hard to remember that her parents loved her, too.
I asked Lydia if she would do a little experiment before the next session, which
was to pretend that she was a detective who was looking for clues that her parents
loved her and cared for her. I suggested that she put a smiley sticker on a chart
that I had prepared for her each time her parents told her that they loved her or
showed that they cared about her. When she brought the chart in to the next session, she was smiling and showed me that she had lots of stickers. I then engaged
her in a reverse role play where I pretended to be her, thinking that my parents
didn’t love me because they paid so much attention to my brother, and she was to
pretend to be the counselor and “help me” with my problem. This proved to be
very effective and she was able to convince me that my parents did love me, but
that my brother was just a helpless little baby who needed them more than she
did because she could do lots of things by herself! On this note, we terminated
counseling.
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DEVELOPMENTAL CHARACTERISTICS
OF MIDDLE CHILDHOOD
During middle childhood, generally considered to be between the ages of 6 and
11, there are many significant changes and developmental milestones. During this
span of several years, there are many “firsts,” primarily associated with school and
friends. Understanding what is characteristic at this stage of development is essential
for helping professionals who must consider how this impacts problem assessment
and intervention.
SELF-DEVELOPMENT
During middle childhood, children’s self-understanding expands. Instead of describing themselves superficially, they have a multidimensional view of themselves
(Broderick & Blewitt, 2014), and, consequently, they are able to describe themselves
in terms of several characteristics at once: “I am a fast runner, a good reader, and
have dark brown hair.” Furthermore, they can provide justification for their attributes: “I’m smart because I got a good grade on a test.” During middle childhood,
they begin to see themselves as having more complex personalities, and they are
beginning to develop a more internal locus of control (Berk, 2017).
As they enter school and begin to compare themselves to others, they become
self-critical, feel inferior, and may develop lower self-esteem (Broderick & Blewitt,
2014). They may be more inhibited to try new things, and they are sensitive to feedback from peers. As they become aware of their specific areas of competence and
more aware of their personal strengths and weaknesses, they may experience either
self-confidence or self-doubt (Berk, 2017). Parents, teachers, and other adult role
models are an important influence in helping children develop positive self-worth.
According to Harter (2012), children develop a concept of their overall worth
at around age 8. At this time, their self-esteem begins to solidify, and they behave
according to their preconceived ideas of themselves. Robins and Trzesniewski (2005)
note that both genders report similar levels of self-esteem during middle childhood.
SOCIAL DEVELOPMENT
During the primary school years, socialization with peers is a major issue. Being
accepted in a peer group and having a “best friend” contribute to children’s sense
of competence. As they learn to deal with peer pressure, rejection, approval, and
conformity, they begin to formulate values, beliefs, and behaviors that facilitate their
social development, according to Feldman (2016). Associating with peers, especially
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those who are different from them with regard to abilities, religion, ethnicity, and
personality, enhances their perspective-taking skills. In addition, they learn to
develop a broader view of the world, experiment with ideas and roles, and develop
other interaction skills. As they participate in activities, they learn to cooperate and
compromise, to make and break rules, to assume roles as leaders and followers, and
to understand others’ points of view (Feldman, 2016).
By age 7, children begin to outgrow their egocentrism and adopt more prosocial
behaviors. As they continue to mature and develop the ability to see things from
another’s perspective, they become more adept at interpreting social cues and evaluating input (Berk, 2017). Consequently, they become better able to resolve conflicts
and solve social problems.
Gender differences become even more distinct at this age. Between ages 6 and 11,
gender segregation between groups of boys and girls and gender-based preferences in
types of play reach a peak. Girls generally engage in more indirect, relational aggression and boys engage in more direct, physical aggression (Björkqvist, 2017). Gender
differences in the form of aggression appear to be cross-cultural (Archer, 2004).
EMOTIONAL DEVELOPMENT
During middle childhood, children’s ability to recognize emotions in themselves and
others increases dramatically. They are also much better able to control their own
emotions and communicate about them both verbally and expressively (Glowiak &
Mayfield, 2016). They are also more sensitive and empathic and begin to experience
more complex emotions such as guilt, shame, and pride. Their fears are related to
real-life, not imaginary, issues.
Children at this age are also increasingly aware that people are capable of having
more than one emotion at once and that there may be a mismatch between how
affect is expressed and the underlying emotion (Glowiak & Mayfield, 2016). They
are beginning to learn that emotional expression depends on the goals and context
of any given situation (Berk, 2017). Consequently, their emotional messages become
more complex and include more blended signals. Moreover, gender differences in
emotional expression are more pronounced with increasing age, with girls showing
more positive emotions than boys, and boys demonstrating more externalizing
emotions than girls (Chaplin & Aldao, 2013).
Children in middle childhood have, for the most part, developed the ability to
regulate their emotions (Glowiak & Mayfield, 2016). Children’s emotional development further predicts the likelihood of school success (Blankson et al., 2017).
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COGNITIVE DEVELOPMENT
According to Piaget (1967), children undergo a transitional period between preoperational and concrete operational thought between the ages of 5 and 7. By age 8,
they have become more concrete operational thinkers. As a result, they are able to
understand reversibility, conservation, reciprocity, identity, and classification and
begin to apply these principles in a variety of contexts such as friendships, rules in
games, and team play, as well as in academic contests (Erford, 2018).
Cognitive progress takes place in many areas during this period. Children become
more capable of suppressing undesirable behavior, maintaining attention, and making
and following through on plans (Best, Miller, & Jones, 2009). Their level of moral
reasoning also grows gradually with age, as they are better able to consider multiple perspectives (Jambon & Smetana, 2014). Although their thinking becomes
more logical and their problem-solving abilities are enhanced, Siegler, DeLoache,
and Eisenberg colleagues (2014) cautioned that their problem-solving abilities are
somewhat limited because they don’t consider other possible solutions. They also
cannot reason abstractly, and they make assumptions and jump to conclusions,
which influences the way they approach situations. For example, if their best friend
does not sit beside them, they assume they did something to make their friend angry,
rather than consider a variety of other possibilities.
In middle childhood, language development continues; they begin to understand
more abstract concepts and use vocabulary in more sophisticated ways (Wray-Lake
& Syvertsen, 2011). Although their vocabularies will expand to more than 40,000
words during middle childhood (Berk, 2017), they still rely on intonation more
than context to help them understand another person’s intentions (Keitel, Prinz,
Friederici, von Hofsten, & Daum, 2013). By the end of middle childhood, they are
more skilled at using language in practical ways such as gossiping, storytelling, and
arguing (Del Giudice, 2018).
PHYSICAL DEVELOPMENT
During middle childhood, skeletal growth decelerates and muscle mass increases
(Payne & Isaacs, 2017). Because of this slow rate of growth, children experience a
high degree of self-control over their bodies. Movement becomes more coordinated
and complex, and children at this level are able to master most motor skills and
become much more agile and adept at running, skipping, jumping, riding a bike,
and skating. By the end of this developmental period, there is a major improvement
in their fine motor proficiency as well (Payne & Isaacs, 2017).
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Because children’s bodies mature at different rates, some 10- and 11-year-olds
are entering puberty (Del Giudice, 2018). Height and weight growth spurts, which
begin at different times for different children, can contribute to self-consciousness
and embarrassment. Sex differences in body composition and muscularity become
more pronounced (Del Giudice, Angeleri, & Manera, 2009).
Before reading further, refer to the “Voices from the Field” sidebar to see how a
professional school counselor informed parents about developmental stages.
VOICES FROM THE FIELD—PROFESSIONAL
Last year as a K–12 school counselor, I published a monthly newsletter and often included some basic points about what to expect at each stage of development. Several parents called with specific questions or concerns about their son
or daughter’s development, so I decided to hold a series of parenting programs
to help parents better understand what to expect as their children mature. I also
included age-appropriate communication and discipline strategies and examples
of typical problems they might expect at each age level. Based on positive feedback from parents, I offered the sessions again this year. I have found this to be
an excellent way to connect with parents, and those attending seem to have
benefitted from the information and sharing.
—Marty, K–12 school counselor
Case Study—Middle Childhood
Carlos, a third-grader, visited the school counselor because he said kids were
picking on him and wouldn’t let him play with them. To get a more accurate picture of the problem, the counselor asked Carlos to act out with small action figures what happened when others picked on him. When he acted out the situation,
the counselor noted that of the 10 action figures involved in the game, only a few
seemed to be actively involved in picking on Carlos—calling him names and trying to prevent him from participating in the soccer game. When questioned about
this, Carlos agreed that not everyone picked on him, but said that he still hated
going out for recess.
The counselor then asked Carlos to tell him more specifically how these kids
picked on him. Carlos discussed, in detail, some of the things they did to him. He
said that what bothered him the most was when they called him a pig and said he
was fat and ugly. The counselor listened carefully to this young client, then took
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out a mirror and handed it to him. “Carlos,” he said, “look into this mirror and tell
me what you see.” Carlos looked in the mirror and said that he saw himself. “Do
you see a fat, ugly kid?” “No,” he responded. The counselor then asked, “Do you
see something with pink ears and a snout in the mirror?” “Of course not,” Carlos laughed. “Then if you aren’t what they say you are, what is there to be upset
about?”
Carlos replied that the kids shouldn’t call him names, and the counselor agreed
that it wasn’t nice to call others names but stressed that we usually can’t control
what others do, so does it really help to get so upset about it? He explained to
Carlos that they might be able to come up with some ideas so that he didn’t get
so upset when others behaved badly toward him.
Together, they brainstormed some things that might help, including pretending that he had earplugs in his ears and couldn’t hear a thing others said. The
counselor also suggested that he might make up a silly song or a limerick that he
could say to himself to make him laugh instead of feeling bad when others called
him names that he knew weren’t true. Carlos liked the idea of the song and, with
a little help from the counselor, he wrote the following (to the tune of Row, Row,
Row Your Boat):
You can call me names if that’s what you like to do,
But I don’t have to listen to you or think that they are true.
So think about what good it does to make such fun of me.
Maybe it would make more sense to just be nice to me.
After developing the song, the counselor suggested that Carlos sing it aloud
several times until he had memorized it. They agreed that Carlos would sing this
to himself the next time his classmates teased him so he could laugh instead of
getting so upset. The counselor also wanted to help Carlos with the problem of
not being included in the soccer game. He asked him to engage in a role play to
show him what happened when the others told him he couldn’t play. Based on his
response in the role play, it appeared that when one or two boys said he couldn’t
play that he just walked away. The counselor asked Carlos if he had any other
options: Did he have to walk away or could he do something else? Carlos said
he couldn’t think of what else he could do, so the counselor suggested that they
do another role play, and this time the counselor would pretend to be Carlos and
Carlos could be the mean boy. When he, as the mean boy, told the counselor he
couldn’t play, the counselor told him that he was a really good player and could
help his team if he would let him play so he could prove it. When the role play
ended, the counselor asked Carlos what he thought about that response—what
did he think might happen? He said maybe they would let him play, but maybe
not. The counselor agreed, but asked him what he had to lose by trying it; it might
work out! But if it didn’t, did he have any other options? After thinking about it,
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he said that maybe he could ask a few other kids who were friendly to him if they
wanted to play their own game.
Before sending him back to the classroom, the counselor asked Carlos what he
had learned during their session. He said he knew he didn’t have to be so upset if
others teased him about things that weren’t true and that he maybe it wasn’t such
a good idea to just walk away if they told him he couldn’t play because then they
were getting their way.
DEVELOPMENTAL CHARACTERISTICS
OF EARLY ADOLESCENCE
Early adolescence, generally considered to be ages 11–14, is a period of tremendous
change. Puberty is the catalyst for adolescence, and young adolescents are impacted
in numerous ways. It is a confusing time for most because they have to contend
with many significant issues unique to this age level. Helping professionals play a
key role in helping young adolescents navigate this period of development, which
Siegel (2014) describes as the culmination of four primary themes: “novelty seeking, social engagement, increased emotional instability, and creative exploration”
(pp. 7–9).
SELF-DEVELOPMENT
The task of identity formation and integration begins in early adolescence (Klimstra &
van Doeselaar, 2017). This is the time when young adolescents explore various possible
options and commit to the choices they make. They also develop a sense of consistency across the identity domains that are personally meaningful or socially salient to
them (Syed & McLean, 2016). For minority youth, ethnicity can play a critical role in
identity development, and ethnicity identity development may moderate the impact
of discrimination and prejudice on their self-esteem (Romero, Edwards, Fryberg, &
Orduña, 2014). In fact, Ponterotto and Pederso (as cited in Holcomb-McCoy, 2005)
stress that “ethnic identity development is as fundamental to the establishment of an
adult’s healthy self-concept and positive intercultural attitudes as are more researched
areas such as occupational identity and political identity” (p. 120).
As young adolescents engage in their search for self, they de-idealize their parents and push for autonomy (Berk, 2017; Keijsers & Poulin, 2013). However, their
increasing individualization comes with a price. The state of frame worklessness
poses many problems, such as a sense of insecurity, for young adolescents (Broderick
& Blewitt, 2014). They are also still immature and lack life experience (Koffman,
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2015). These contrasts, coupled with their cognitive, physical, and pubertal changes,
leave them vulnerable. As a result, they may show increased dependency, which can
be confusing to them and to the adults in their lives.
In some ways, young adolescents contradict themselves. They want to be unique, yet
they want to look like everyone else. Young adolescents’ brain development influences
the unique aspect of behaviors that emerge in young adolescence—self-consciousness
and egocentrism (Somerville et al., 2013). They assume that everyone is looking at
them for thinking about them and are preoccupied with social evaluation. Elkind
(1998) termed this belief that others are as concerned with them as they are about
themselves as the imaginary audience. As a result of this type of thinking, young
adolescents fantasize about how others will react to them and become overly sensitive
about their performance and appearance.
At the same time, young adolescents assume that because they are unique, they
are invulnerable. Elkind (1998) labeled this the personal fable, the belief that bad
things can happen to others but not to them because they are special. The personal
fable accounts for self-depreciating, self-aggrandizing, and risk-taking behaviors
(Alberts, Elkind, & Ginsberg, 2007).
Cross-culturally, following the transition to middle school, young adolescents’
self-esteem declines as they are undergoing drastic physiological and environmental
changes (Shoshani & Slone, 2013). The drop is more pronounced in young females
than males (Bleidorn et al., 2016).
SOCIAL DEVELOPMENT
Peers play an increasingly significant role in young adolescents’ lives and are an
important part of their socialization. This is the period when cliques and distinct
groups emerge, with specific “rules” about how to dress and behave. Because young
adolescents look to peers as a source of support (Cicognani, 2011), they are sensitive
and vulnerable to humiliation by peers (Dishion & Tipsord, 2011). Thus, while peer
relationships can be a source of pleasure, they also can be negative, and dealing
with rejection is a major stressor at this age. Furthermore, bullying increases during
middle school, and peer victimization is linked to many negative mental health,
social, and academic outcomes (Hymel & Swearer, 2015).
Because they have a strong need to belong and to be accepted, young adolescents
have to learn to contend with peer pressure and decisions about which group
to associate with (Tillfors, Persson, Willen, & Burk, 2016). Research shows that
the presence of peers affects how likely adolescents are to take risks (Gardner &
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Steinberg, 2005), but Broderick and Blewitt (2014) also note that high levels of
parental monitoring can protect young adolescents, especially minority teens,
from high-risk behaviors.
Young adolescents also struggle with popularity. Fitting into a group seems to
be based on figuring out what the group is doing, and the better able they are to do
this, the more popular they will be. However, recent studies also show that proactive adolescent aggression that is planned and goal oriented can be associated with
high status among peers and socially competent behaviors (Stoltz, Cillessen, van
den Berg, & Gommans, 2016). During early adolescence, females who use more
relational aggression may be perceived as more popular (Gangel, Keane, Calkins,
Shanahan, & O’Brien, 2017).
EMOTIONAL DEVELOPMENT
Many young adolescents ride an emotional roller-coaster. They are more emotionally volatile and moody, and emotional outbursts are common (Broderick
& Blewitt, 2014). Troublesome emotions such as anxiety, shame, depression,
guilt, and anger occur more frequently than at other age (Avenevoli, Swendsen, He, Burstein, & Merikangas, 2015; Chaby, Cavigelli, Hirrlinger, Caruso,
& Braithwaite, 2015). These negative emotions can be overwhelming and cause
adolescents to feel vulnerable, so they often mask their feelings of fear and vulnerability with anger. This response typically distances people and often results
in increased conflict with adults, who all too often react with anger and fail to
recognize the underlying feelings. Read about an adolescent’s perspective on
anger in the sidebar on this page.
VOICES FROM THE FIELD—ADOLESCENT
When I turned 14, I thought I was going crazy. I would get angry over the slightest
thing and then yell at my friends or my parents. I was getting in trouble home and
at school, so my parents made me go to see the school counselor. I thought he’d
lecture me or send me to the principal, but after he listened to me talk about my
anger he explained that it is pretty typical at this age. He gave me a checklist and
a short book to read. I started seeing him weekly and it helped a lot.
—Ryan, age 14
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Adults who interact with young adolescents must recognize their emotional vulnerability and not exacerbate the problem by reacting insensitively. Educating them
about what they are experiencing is also essential because it if far too easy for them to
feel overwhelmed by their negative emotions and deal with them in unconstructive
ways. Furthermore, it is important to help parents and teachers understand what
these youth are going through and for schools to be developmentally sensitive.
COGNITIVE DEVELOPMENT
Cognitive development during early adolescence is primarily due to the gradual
growth of the brain. At around age 11 or 12, the gradual shift from concrete to formal
operational thinking begins, and this shift is extremely significant. As they move into
more formal operational thinking, they start to think more abstractly, develop the
ability to hypothesize, identify variables that might impact an outcome, and deduce
logical, testable inferences (Arnett, 2014). Also, brain changes in areas that are related
to high-order functions such as planning, self-control, emotional regulation, and
consciousness are occurring (Fuhrmann, Knoll, & Blakemore, 2015). Because most
adolescents do not reach formal operational thinking until mid to late adolescence, it
is easy to assume that they are capable of more mature cognitive development than
they are, so living and working with them can be confusing (Berk, 2017).
During early adolescence, there is considerable individual variability in the extent
to which formal operational thinking not only is attained, but is consistently applied
(Erford, 2018). Furthermore, young adolescents often do not apply these skills to
themselves. For example, they may apply their skill in logic to mathematics problems but not logically assume that if they stay out past their curfew there might
be consequences. Young adolescents are also unable to link events, feelings, and
situations. As a result, they may fail to connect failing a test with not studying for
it, or not associate being grounded with coming in late.
As noted, the transition from concrete to formal operations occurs gradually
and concurrently with brain development (Scott & Saginak, 2016). Also, there is
now growing evidence that there are cross-cultural differences in development
(Kuwabara & Smith, 2012), so counselors must not only consider the cognitive stage,
but also the cultural factors.
PHYSICAL DEVELOPMENT
During early adolescence, dramatic physical changes occur more rapidly than
at any other time in the lifespan, with the exception of infancy (Broderick &
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Blewitt, 2014). Puberty signals the beginning of the adolescent growth spurt,
characterized by a rapid gain in height and weight, accompanied by changes in
body proportions (Berk, 2017). The increased production of the sex hormones
and the changes associated with puberty begin at about age 8 or 9, although this
varies considerably (Berk, 2017). Following the onset of puberty, maturation of
the reproductive system and the appearance of secondary sex characteristics
appear. On average, puberty occurs around age 12 1/2 for girls and around age
13 1/2 for boys in North America (Berk, 2017). However, the timing of puberty
is affected by genetic factors and varies from individual to individual (Wohlfahrt-Veje et al., 2016).
Although young adolescents’ rates of maturity vary tremendously, self-consciousness and anxiety are common. Males and females alike may become clumsy and
uncoordinated for a time because the size of their hands and feet may be disproportionate to other body parts. The impact of puberty on the brain makes adolescents
particularly susceptible and hypersensitive to their social environment and peer
comparisons. For girls, early sexual maturation is associated with greater stress.
Early-maturing girls are more prone to depression and other adjustment issues
because they feel different from their peers. By contrast, early maturing boys report
more confidence and are more likely to be leaders than those maturing on time or
late (Broderick & Blewitt, 2014).
The physical and hormonal changes characteristic of early adolescence can cause
young adolescents to become confused. They are curious about sex; sexual thoughts
and feelings abound, often accompanied by feelings of shame and guilt. These feelings are even more pronounced for those who are questioning their sexual identity.
Straightforward information about sex and sexual preference is extremely important
prior to and during early adolescence.
As you have read, this can be a confusing period of development. Refer to the
“Now Try This!” sidebar and practice explaining puberty to young adolescents.
NOW TRY THIS!
If you are working with adolescent clients, try explaining some of what you
read to help them understand more about what happens when they go
through puberty. If you aren’t working with anyone, ask teenage relatives
or neighbors if they would be willing to meet with you. Ask them for their
reaction—was it helpful to have this information? Why or why not?
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Case Study—Early Adolescence
Amanda, age 14, was referred to me (Ann) by her parents who were concerned
because she was very moody and also seemed quite depressed. They also noted
that she became very upset with herself when she didn’t get perfect grades.
Amanda was very amenable to therapy and during the first session shared
that she was so confused by her moods—one minute she could be laughing and
having a good time, and the next minute she could be “down in the dumps.” She
said that she had been feeling like this for several months. Amanda was quite
capable of articulating how she experienced her mood swings but at the same
time seemed to think she was the only one who felt like this, which resulted in her
feeling “different.” As a first step, I explained to Amanda that moodiness and depression were quite common at this age as a result of the hormonal changes associated with puberty, going into some detail about why the mood swings occurred.
I also shared a story with her, written anonymously by another one of my clients,
“Like a Yo-Yo” (Vernon, 1998), which described another girl’s mood swings. Amanda identified with the content of the story and expressed relief that she wasn’t the
only one who had these up-and-down mood swings. After talking more about her
mood swings, and depression in particular, I asked her to complete a depression
checklist (Vernon, 2009) and a mood chart as a homework assignment for the next
session (Vernon, 2002).
When I met again with Amanda, we reviewed the mood chart and checklist,
which clearly depicted numerous characteristics of depression, as well as both
mood swings and significant depressive episodes. We discussed whether there
were any triggers for her depression, and she said that usually her feelings came
out of nowhere, but at other times they were related to rejection by friends or receiving a bad grade. I helped her identify her beliefs about each of these events.
Based on her responses, I explained to her how overgeneralizing, catastrophizing, and self-downing contributed more to her depression. Then I asked her to
draw around her hand and write these irrational beliefs about being rejected or
getting a bad grade on the fingers of the hand. We worked on ways to dispute
these thoughts, and I asked her to write specific disputes in between the fingers.
This served as a visual reminder of how to challenge beliefs that contributed to
her depression. Once again I asked her to complete a mood chart throughout
the week.
After reviewing her mood chart during the next session, I asked Amanda to
give me a specific example of something that had depressed her that week.
She described getting into a fight with her best friend. I helped her distinguish
between facts and assumptions, which proved to be very important because
when she assumed that her friend didn’t like her, she felt depressed—but since
she didn’t have any facts to back up her assumption, she agreed that it wasn’t
helpful to her to think in this way. We continued to work on other factors con-
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tributing to her depression, identifying irrational beliefs and how to dispute
them.
At the next session Amanda shared that it was so difficult to fight this depression that she felt like giving up. I asked her to think about good things in her
life—reasons she had to live, and as she identified these reasons, I wrote them
down for her. I suggested that she make a depression “tool box,” (Vernon, 2009),
explaining that she could put artifacts inside the box—something to represent
each thing on her list. She could also add uplifting music, rational coping statements, inspirational quotes, or other things that would help her remember positive aspects of her life and ways to cope with her depression. She later reported
that this was very helpful.
I continued to work with Amanda and used other strategies to help her deal
with her depression, such as writing the lyrics to sad songs she typically listened
to when she was depressed and making them “better” by rewriting the lyrics. She
continued to keep the mood chart, and I also focused on helping her identify and
dispute irrational beliefs that contributed to her depression. Over the course of
several months Amanda was finally much less depressed.
As this case illustrates, young adolescents are frequently overwhelmed by their
mood swings and depression, so counseling practitioners need to identify very specific ways to help them address these issues. Helping them “get better” is the goal.
DEVELOPMENTAL CHARACTERISTICS
OF MID-ADOLESCENCE
Counseling the mid-adolescent is easier than working with younger adolescents,
but a lot depends on the extent to which the adolescent has attained formal operational thinking. In general, there is less emotional turbulence, but adolescents at
this stage are dealing with more complex relationships and decisions about their
future. Mid-adolescence serves as a stepping stone to the young adult world with
its even greater challenges and new opportunities.
SELF-DEVELOPMENT
Adolescents at this stage are preoccupied with achieving independence and discovering who they are and are not (Erford, 2018). Finding themselves involves
establishing a vocational, political, social, sexual, moral, ethnic, and religious
identity. They do this by trying on various roles and responsibilities; engaging
in thought-provoking discussions; observing adults and peers; speculating about
possibilities; dreaming about the future; and doing a lot of in-depth self-questioning, experimenting, and exploring. During this period of development, they may
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spend more time alone, contemplating ideas and trying to clarify their values,
beliefs, and direction in life.
Adolescents at this stage of development are generally more self-confident than
they were previously and do not feel the need to look like carbon copies of their
peers. Actually, they may strive to do the opposite, such as wearing quirky clothes
from secondhand stores to “make a statement.” Their self-assertion extends to other
areas as well. They are more capable of resisting peer pressure because they are more
self-confident and less egocentric (Erford, 2018), and they also have the ability to
look beyond the immediate present and speculate about long-term consequences
of succumbing to peer pressure.
Whether the genders differ in the process of identity formation has been the topic
of considerable discussion. Research indicates that, overall, girls are more advanced
in the development of identity formation in early adolescence, but boys catch up
with them by late adolescence (Klimstra, Hale, Raaijmakers, Branje, & Meeus, 2010).
Cultural values also contribute to identity development, as our sense of self reflects
an awareness of how others see us. Umaña-Taylor and colleagues (2014) note that
ethnic and racial identity is central to the development of youth of color. They assert
that changes in social environmental context (e.g., more exposure to diversity) can
lead to an increase in relevance of ethnic identity.
SOCIAL DEVELOPMENT
Peer relationships continue to be important during mid-adolescence, but adolescents
at this stage grow less susceptible to peer pressure. However, they do spend more
time with peers, and this serves several important functions of trying out various
roles (Broderick & Blewitt, 2014; Erford, 2018), learning to tolerate individual differences, and preparing themselves for adult interactions as they form more intimate
relationships (Berk, 2017).
If they have attained formal operational thinking, adolescents at this stage approach
relationships with more wisdom and maturity. With their higher level of self-confidence, they do not depend so much on friends for emotional support, and they begin
to select friendships based on compatibility, common interests, shared experiences,
and what they can contribute to the relationship (Broderick & Blewitt, 2014). Between
14 and 18 years of age, across sex, ethnicity, and socioeconomic status, resistance
to peer influence rises linearly (Steinberg & Monahan, 2007). Meanwhile, problem
behaviors, such as risk taking and risky decision making, decrease with age, according to Dishion and Tipsord (2011).
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During this time, intimate friendships increase, which helps adolescents become
more socially sensitive. Females perceive more social support from peers than
males do, their friendships are more intense, and their development of intimacy is
more advanced than it is for males (Bokhorst, Sumter, & Westenberg, 2010). Also,
females are more advanced in the development of perspective taking and empathy
(Van der Graaf et al., 2014). As they become less egocentric, they are better able
to recognize and deal with the shortcomings that are inevitable in relationships.
As a result, friendship patterns become more stable and less exclusive (Broderick
& Blewitt, 2014). Dating and sexual experimentation generally increase during
this period, and teenagers are more likely to be sexually active now than before
(Erford, 2018).
EMOTIONAL DEVELOPMENT
As they gradually attain formal operational thinking, adolescents have fewer rapid
mood fluctuations and, therefore, are not as overwhelmed by their emotions. They
tend to be less defensive and are more capable of expressing their feelings rather
than acting them out behaviorally (Allen & Miga, 2010). The increased emotional
complexity that occurs during this period enables adolescents to identify, understand,
and express their emotions more effectively, as well as be more empathic (Van der
Graaff et al., 2014).
A compounding factor in adolescents’ emotional development is depression,
which, according to Newman and Newman (2017), 35% of adolescents experience
to some degree. Toward the end of this developmental stage, many adolescents are
lonely and ambivalent. As their needs and interests change, they may be gradually
growing apart from their friends. As high school graduation approaches, they might
be apprehensive about the future and experience self-doubt and insecurity if they
compare themselves to peers or when they explore the skills and abilities they need
to qualify for a certain job or for postsecondary education.
Once they have achieved formal operational thinking skills, adolescents are better
able to deal with emotionally charged issues. They are not as impulsive or as likely
to behave irrationally or erratically in response to emotional upset. How adolescents
at this stage of development manage their emotions varies depending on their level
of cognitive maturation.
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COGNITIVE DEVELOPMENT
Formal operational thinking and inhibitory control continue to develop during
mid-adolescence, and their new cognitive capabilities allow 15- to 18-year-olds to
think and behave in significantly different ways than before. For example, as they
develop the ability to think more abstractly and flexibly, they can hypothesize, can
explain the logical rules on which their reasoning is based, and are less likely to
conceptualize everything in either-or terms (Newman & Newman, 2017). Formal
operational thinking moves adolescents into the realm of possibility, so their thinking
is more multidimensional and relativistic (Osherson, 2017). During mid-adolescence,
they are capable of pondering and philosophizing about moral, social, and political
issues and are better able to distinguish the real and concrete from the abstract and
possible (Broderick & Blewitt, 2014; Osherson, 2017).
Although their cognitive abilities have improved considerably since early adolescence, adolescents between the ages of 15 and 18 are still likely to be inconsistent in
their thinking and behaving. They still possess self-focused thoughts that hinder
them from engaging in objective and logical self-evaluation and problem solving
(Broderick & Blewitt, 2014).
PHYSICAL DEVELOPMENT
Typically, by about age 15 for females and 17 for males, the growth spurt ends.
Depending on when they enter puberty, the 15- to 18-year-olds’ physical development might continue rather rapidly or slow down gradually. Because males typically
lag females in the rate of physical development in early adolescence, females tend
to tower over males until this trend is reversed in mid-adolescence (Broderick &
Blewitt, 2014). By mid-adolescence, females usually have achieved full breast growth,
are menstruating, and have pubic hair. Males experience a lowering of their voice,
and facial hair appears approximately by age 15 (Berk, 2017).
Sexual urges are strong during mid-adolescence, which can evoke anxiety in
adolescents and their parents. Becoming sexually active is often unplanned and
most adolescents have knowledge about the risks of sexually transmitted diseases
and pregnancy. Still, unprotected sex is common because they often do not think
they need to use contraception or are influenced by alcohol or peer pressure (Brown
& Guthrie, 2010). Although most teenagers aren’t having intercourse on a regular
basis, sex education is imperative (Martinez, Abma, & Copen, 2010).
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Now that you know more about adolescent development, refer to the “Add
This to Your Toolbox” sidebar for an intervention that educates students about
development.
ADD THIS TO YOUR TOOLBOX
A good way to introduce a discussion about developmental characteristics to
a class of adolescents is to divide students into groups of six and give each
group a bag of objects that they have to incorporate into a skit. The objects
should represent their developmental stage. For example, for this age group,
objects could include car keys, school books, yearbooks, beer cans, cigarettes, and so forth. After they have performed the skits, debrief by discussing the content and then share information about adolescent development.
Case Study—Mid Adolescence
Kai’s father, a single parent, referred him to my (Ann’s) mental health practice
because Kai was a senior in high school and had no idea what he wanted to do
after graduation. The father also noted that his son wasn’t spending as much time
with his friends and hadn’t committed to going out for track, a sport in which he
excelled. When he asked Kai what was going on, Kai refused to talk about it and
seemed anxious if others asked about his plans for the future.
During the first session, Kai was reluctant to talk, so the first thing I did was
to reassure him I often worked with high school seniors who were ambivalent or
confused about the future. I invited Kai to read several short journal entries written anonymously by another client with similar concerns, thinking that this would
help normalize his feelings. After he finished reading, I gave him paper and pencil
and invited him to jot down any reactions, specifying that he didn’t need to share
these if that was his desire.
After he finished writing, I told him that I had a sorting activity that might help
him with his future plans. I handed him a “What’s Next?” sorting board divided
into three columns, very likely, somewhat likely, not very likely, and a packet of
cards that contained various after-high-school options such as full-time job in
the community, trade or technical school, two-year college, four-year college,
and so forth (Vernon, 2002). I invited Kai to read the cards and place them in
the categories according to his priorities. This intervention, which required no
verbalization on Kai’s part, seemed to interest him and he appeared to take it
quite seriously.
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By the end of the first session, I could see that Kai was more relaxed and had
gained some insights from these interventions. I asked Kai if he would be willing
to come back again to work more on his future plans, and he said yes. During
the second meeting, I explained that in any transition, such as graduation, roles,
relationships, routines, and responsibilities change. I handed him a sheet of paper
divided into four squares with one of these words listed in each square. I invited
Kai to write whatever came to mind relative to the changes in each of these four
areas and any feelings he had about graduating. He was willing to share this, and
based on what he wrote, the main issue was losing connections with his friends
when they went their separate ways.
At the third session, I reviewed some of the things we had discussed during
previous sessions and suggested that we do a loss graph. I explained that the
purpose of this intervention was to help him get more in touch with his memories
about middle school and high school. I asked Kai to draw a line across a sheet of
paper and divide it into years, eighth grade, ninth, and so forth, and write down
things he remembered about each year, placing the positive memories above the
line and the negative ones below. I also encouraged him to look back through
photos as a way to help him remember these years. Kai spent a considerable
amount of time on this activity and was willing to share some of his memories with
me. We discussed some ways by which Kai could reach closure with friends who
were moving away from the community. As a homework assignment, I suggested
that he visit with the school counselor to review the interest inventories he had
completed during his junior year.
During the next session, Kai shared the information relative to the interest
inventories and we talked more directly about his options. We reviewed the sorting
board intervention that he had completed during the first session and asked if he
would make any changes. He said he wasn’t sure, so I took several sheets of paper
and wrote one option on each sheet in one column. I labeled the next column
“advantages” and the next column “disadvantages.” Together, we identified and
discussed the advantages and disadvantages of each option, and, based on these
responses, I asked if there were any options he could eliminate. He was able to do
this, and then we discussed the other options while also referring to the information
from the career interest inventories. After a few more sessions, Kai seemed less anxious and ready to move on. He had decided to go to college and try out for track
and was busy filling out scholarship applications.
As you have probably surmised, growing up can be challenging. What was it
like for you? Refer to the “Personal Reflections” sidebar and think back.
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PERSONAL REFLECTION
Think back to your childhood and adolescence. Which stages in particular
stand out for you? Which stage was most troublesome and how did you
deal with the challenges? In what ways do you think growing up today is
like or unlike what you experienced?
TAKE-AWAYS FROM CHAPTER 1
As we conclude this chapter, we would like to refer to the vignette at the beginning
of the chapter and share what I (Ann) learned from working with this client, as well
as a technique I used that I think was effective. Perhaps the most important thing
that was reinforced for me is that symptoms of depression are very similar to developmental characteristics during adolescence, so it is difficult to distinguish between
the two. This is why it is so critical to be informed about development, and when
armed with this information, counselors can make more accurate assessments. As
was the case with Mrs. Jacobs, without this developmental “barometer,” parents and
professionals can easily misconstrue or misdiagnose problems; with it, they have a
general sense of what’s “normal.”
I think the most effective thing I did with Mrs. Jacobs was to share information
about what is “normal” at this stage of development. I also think it was important
to support Megan in her “search for self,” which is a critical task at this stage of
development.
After reading this chapter, you should now be more knowledgeable about these
key points:
•
The importance of taking developmental and cultural factors into consideration
regarding assessment and treatment with children and adolescents
•
How levels of development impact how children and adolescents respond to
typical developmental problems as well as more specific situational issues
•
Specific developmental characteristics during early and middle childhood and
early and mid-adolescence
•
Examples of developmentally appropriate interventions as illustrated through
case studies
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•
The importance of sharing information about developmental characteristics
with parents and teachers, as well as with child and adolescent clients
•
How exciting, but also how challenging, growing up can be!
HELPFUL WEBSITES
Society for Research on Adolescence
http://www.s-r-a.org
Developing Adolescents
A reference for professionals: http://www.apa.org/pi/families/resources/
develop.pdf
Child Trends
http://www.childtrends.org
Cleveland Clinic
http://www.my.clevelandclinic.org/health/
articles/7060-adolescent-development
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Vernon, A., & Barry, K. L. (2013). Counseling outside the lines: Creative arts
interventions for children and adolescents—Individual, small group, and
classroom applications. Champaign, IL: Research Press.
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CHAPTER 2
The Individual Counseling Process
Sarah I. Springer, Jean Sunde Peterson, Lauren Moss,
and Ann Vernon
LEARNING OBJECTIVES
1.
To identify specific considerations for working individually with children and
adolescents
2.
To describe the counseling process and necessary skills when working with
young clients
3.
To identify developmentally appropriate interventions for children and
adolescents
C
ara’s parents brought their 12-year-old daughter to my (Sarah’s) private
practice counseling office after experiencing what they described as panic
attacks and bouts of anxiety believed to be impacting her school work and
engagement with extra-curricular activities. The parents had first contacted Cara’s
school counselor to discuss their concerns and she referred them to me to help
address the anxiety and panic attacks. During the intake session with both parents,
I learned that Cara regularly complains of headaches and scratches her legs until
they bleed when she feels anxious. According to the parents, Cara also struggles
with academics and peer relationships. They shared that the school counselor had
recently invited Cara to join a social skills group, which they hoped would help
her feel more comfortable with her peers. During further discussion about what
might be contributing to Cara’s anxiety, her mother said that according to the
school counselor, during a classroom guidance lesson, Cara had identified with a
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peer’s concerns about his parent’s relationship and the possibility that they might
divorce. Cara’s mother also shared that she and her husband are contemplating
separation but have yet to share this information with their daughter. Based on
what the school counselor had shared regarding Cara’s reaction to her classmate’s
concerns about his parents, Cara’s mother thought perhaps their daughter was more
aware of their family situation than they realized. Both parents expressed concern
about how this stress might impact Cara, especially with her upcoming middle
school transition. After discussing their counseling goals for Cara, I asked them
to sign a release of information so that the school counselor and I could consult
and coordinate services. We set up an appointment for me to see Cara individually,
and I suggested that the parents consider seeing a marriage counselor to help them
deal with their marital issues, which were most likely impacting their daughter.
At the beginning of the first session, Cara sat on the corner of the couch with arms
and legs crossed, glancing at every aspect of the office except me. Her body language
and “I don’t know” answers suggested that she felt uncomfortable and “put on the
spot” when questioned about her situation. After I provided some simple introductory
statements about myself and the counseling process in general, I suggested moving to
the beanbag chairs near a basket containing magazines and scissors. Together, we spent
the rest of the session looking through the magazines and making a collage of pictures
and words that depicted things about us, such as what we liked or valued. I began the
dialogue by identifying a picture that appealed to me and modeling an explanation
of its connection to my life—in this case, the Nike symbol, because it reminded me of
playing basketball with friends. This modeling seemed to help Cara relax, and we began
alternating, talking about how each of our pictures reflected something about ourselves.
This vignette illustrates a complex case involving a pre-adolescent who was experiencing anxiety as a result of familial, academic, and relational stressors. Issues
highlighted in this vignette are not atypical in the daily work of school and mental
health counselors. Some counselors trained to work with children and adolescents
draw from a repertoire of effective strategies and enjoy working with problems
common to this age group. Others are uncomfortable with young clients and with
their issues. Although the American Counseling Association Code of Ethics (2014)
requires that counselors have the “appropriate education, training, and supervised
experience” to work with specialty populations (p. 8), deficits in counselor confidence and skill suggest an “enormous service delivery shortfall” (Prout, 2007,
p. 4). To help close the gap between client needs and counselor skills and abilities,
counselors working with young clients need to refine their understanding of child
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and adolescent development and incorporate appropriate skills that address their
unique needs (Broderick & Blewitt, 2015; Shokouhi, Limberg, & Armstrong, 2014).
If you haven’t had much experience with children or adolescents and might be
uncomfortable, follow the suggestions in the “Now Try This” sidebar.
NOW TRY THIS!
Many novice counselors or counselors in training fear working with young
clients because they haven’t spent much time around them. The best way to
increase your comfort with children and adolescents is to go to a local park
or playground or volunteer in a school or summer camp. Observe, interact,
and engage with these young people. We suggest that you interview several children and adolescents (with parental permission), asking them what
is the best or worst thing about being their age, what they worry about at
this age, what kinds of problems kids their age have, and what would they
would like adults to know about what it is like being this age.
This chapter reviews skills and effective strategies for counselors who work with
children and adolescents, discusses how to build rapport with this unique population, and describes the counseling process. In addition, ethical considerations and
confidentiality, as they apply to children and adolescents, will be addressed.
CONSIDERATIONS FOR WORKING
WITH YOUNG CLIENTS
Imagine that you are 12 years old and your father takes you to see a mental health
counselor because you were caught trying to steal a video game. If you were that age
and you had never seen a counselor, the first thing that might pop into your mind is
that the counselor might think you are a bad kid and would recommend punishment. If
this were the case, would you want to be in counseling? For a variety of reasons, young
clients can be more difficult to connect with, which makes it imperative that counselors
working with this population understand what it is like to walk in their shoes. You
might consider the following best-practice recommendations from various experts:
1.
Respect young clients’ behaviors, such as reluctance. Reluctance is common
and normal. Utilizing creative, nonverbal techniques, such as art and play, can
help to lessen anxiety and support a strong relational foundation (Roaten, 2011).
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2.
Maintain patience, especially with difficult children (Henderson & Thompson,
2016).
3.
Help children understand the counseling process by using concrete language
(Kress, Paylo, & Stargell, 2019) and creative interventions (Vernon, 2017).
4.
Balance authenticity and flexibility with predictability in the structure and
boundaries consistently communicated throughout sessions (Kress et al., 2019).
5.
Listen to young clients’ metaphors and join their language (Roaten, 2011).
6.
Partner with young clients in the goal-setting process and, when possible, offer
them freedom to choose next steps toward these goals (Roaten, 2011).
7.
Be nonreactive, collaborative, and respectful of young clients’ need for personal
space and individual expression (Peterson, 2007).
8.
Avoid forcing strategies, as this may take away a client’s sense of autonomy
and drive a wedge in the relationship (Kress et al., 2019).
9.
Maintain a holistic approach through honoring young clients’ strengths and
resiliencies (Kress et al., 2019; Vereen, Hill, Sosa, & Kress, 2014).
10.
Do your best to see things from the young clients’ perspectives (Vernon, 2009).
They need to know that you “get” what it is like to be in “their world.”
11.
Recognize developmental characteristics of children and adolescents at various
stages and how these impact their social and emotional experiences (Kress et
al., 2019). Take these developmental considerations into account and implement
appropriate interventions accordingly (Roaten, 2011).
12.
Consider the social context and systemic structure surrounding children. A
systemic perspective, gained through consultation with significant adults in
the child’s life, can provide valuable insight (Kress et al., 2019; McMahon,
Mason, Daluga-Guenther, & Ruiz, 2014).
13.
Collaborate with other stakeholders, such as teachers, who interact with
young clients on a regular basis and can observe them extensively (Coogan,
2018). School counselors, however, should remain sensitive to teachers’ time
constraints and the need for information about the counseling process
(Kottman, 2011).
14.
Adapt the length of the session and the approach to the setting and the needs
of the young client (Kress et al., 2019).
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15.
Differentiate counseling approaches according to ability level and learning
style, paying special attention to children with advanced and delayed/limited
intellectual capacity (Auger, 2013; Colangelo & Wood, 2015).
While these general guidelines are applicable to young clients of all ages, there
are some additional considerations in working with adolescents. As you read in
chapter 1, adolescents are moving through uncertain territory, especially as they
differentiate themselves from parents and siblings. Counselors should acknowledge
and normalize the discomfort and uncertainty of this process. They must also realize that trust is often more difficult to achieve with adolescents than with children,
so rapport may be more tenuous. Though some adolescents might be suspicious of
more casual conversation, it might also be productive, and unexpected personal
connections can occur.
Some adolescents may be accustomed to “walking on eggshells” or even shutting
down emotionally with adults. Therefore, prying for personal information, particularly too early in the counseling relationship, can have a negative impact on the
therapeutic alliance. In contrast, low reactivity and respect, as illustrated in the
following examples, is more productive (Peterson, 2007).
•
“Sometimes I feel so bad that I get scared at how bad I feel.” (Counselor: “That
sounds frightening … to feel that bad. Tell me more about that. What’s scary?”)
•
“Like when you came to our class and talked about violence with a guy you’re
going out with? That’s happened to me.” (Counselor: “I’m so sorry that you
had that experience. I imagine it was hard to share that with me and I’m glad
that you trust me enough to confide in me. I wonder if we could talk a bit
more about it.”)
Verbal “bombshells,” such as these, may be meant to test counselors personally or
to find out whether something actually can be talked about. A counselor’s attentive
responses can help adolescents know that it is okay to bring up and share difficult
issues. Perhaps, quite unlike the high reactivity that may exist in the adolescent’s
home, the counselor’s poise, attention, and affirmation will lead to trust. Validating
the client by saying, “Wow. That sounds like a very difficult situation” can be effective. Counselors should also be on the lookout for statements that indicate possible
suicidal ideation, such as the statement in the first example, asking, “How much
should I worry about you?”
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Given the vulnerabilities associated with childhood and adolescence, counselors
should also remain aware of their own triggers and recognize that enmeshment or
over-involvement in young clients’ lives may pose a threat to the counselor-client
relationship. For example, counselors may find themselves losing objectivity by
wanting to “rescue” young clients or second-guessing their parents or other stakeholders. This threat increases when the counselor connects at an emotional level
with clients’ concerns, including vulnerabilities and lack of autonomy. Through
supervision, consultation, and/or personal counseling, counselors should bracket
their own values and biases in order to be able to clearly examine their clients’
needs (ACA, 2014).
DEVELOPMENTAL CONSIDERATIONS
As discussed in more depth throughout chapter 1, developmental changes occur
continuously in childhood and adolescence. Therefore, counselors need to be knowledgeable about child and adolescent developmental processes, including the ability
to distinguish among normal developmental deviation, pathology, and minor crises
(Kress et al., 2019). To maintain this level of discernment, counselors must carefully
consider the presumed physical, cognitive, social, and emotional development of
a young client before the first meeting and throughout the counseling process.
Counselors should also remain alert to developmental anomalies, including atypical
development, in which intellectual, social, physical, and emotional growth are not
consistent with expected chronological milestones (Land, Tuttle, & Moss, 2017).
When appropriate, counselors may choose to gain a more comprehensive picture
of clients’ development by exchanging observations and information with teachers
and parents (Ziomek-Daigle, 2017).
CULTURAL CONSIDERATIONS
When working with children and adolescents, as well as their parents, counselors
should be aware of cultural differences in behaviors and communication styles
(Jayne, Stulmaker, & Purswell, 2013). For example, cultures differ in norms related
to eye contact, proximity, response to stress, socioeconomic and sociocultural circumstances, and the interpretation of the meaning of each of these values and
preferences (Sori & Hecker, 2015). Culturally responsive counselors keep acculturation and ethnic identity in mind—both of which occur on a continuum (Swan,
Schottelkorb, & Lancaster, 2015). Accurately assessing needs of individual clients is
important for providing effective, culturally competent counseling (Ratts, Singh,
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Nassar-McMillan, Butler, & McCullough, 2016; Jayne et al., 2013). Read more about
cultural considerations in chapter 9. Take a moment to focus on the sidebar on this
page and read one practitioner’s caution regarding overemphasizing cultural norms.
VOICES FROM THE FIELD—PROFESSIONAL VOICE
At the end of the day, you need to do what’s best for YOUR client. This is where
your clinical judgment and skills really come in. I teach a class on intercultural
counseling skills to graduate students in counseling, and I emphasize the importance of knowing cultural norms, but not generalizing them. In other words, it is
important to ask clients about their specific experiences and cultural understanding. That is the only way you can really feel confident about the way in which you
interact with your clients and conceptualize their cases.
—Helen, licensed psychologist and school counselor
WHY DO CHILDREN AND ADOLESCENTS
NEED COUNSELING?
There are still people who wonder why children and adolescents need counseling,
but as discussed in chapter 1, children and adolescents have to contend not only with
issues related to their growth and development, but also with more serious situational
or psychological problems. According to Henderson and Thompson (2016), the most
typical problems for this population include the following: interpersonal conflicts
(difficulty relating with parents, teachers, siblings, peers), intrapersonal conflict
(difficulty making decisions and identifying alternatives and consequences), lack of
self-awareness (difficulty identifying their strengths, abilities, weaknesses, values,
and behaviors), lack of information about the environment (failing to understand
what it takes to be successful in school and life in general), and lack of skill (study
skills, communication skills, problem-solving skills, and personal safety skills).
In schools in particular, many children and adolescents present with typical developmental problems such as those listed. Much of the focus is on skill building and
prevention. As they reach adolescence, more significant problems with depression
and anxiety, suicide ideation, gender identity confusion, eating disorders, substance
abuse, and the like are more prevalent. School counselors may not have the time
to address these issues given their other responsibilities, which is why many of
these cases are referred to clinical mental health counselors. Working together as
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professionals is a critical factor in providing comprehensive services to troubled
youth. Throughout this book, you will learn more about challenges that children
and adolescents experience and what counselors can do to help.
BASIC COUNSELING SKILLS
According to Sheperis and Ellis (2014), “[E]ffective helping involves being present
and attentive to clients through a variety of clinical approaches and techniques”
(p. 170). As these authors noted, helping clients “combines the art of understanding
and ‘being with’ another person with the research basis of what works” (p. 171).
Obviously, active listening is basic to building rapport and defining the problem
and is essential throughout the counseling process (Peterson, 2007). The counseling
interview is facilitated when counselors use encouragers, paraphrases, reflections
of feelings and meanings, and summarization skills (Vernon & Davis-Gage, 2018).
Encouragers—non-verbal expressions—are especially powerful when the counselor
uses a short key word or short phrase used by the client (Moss & Glowiak, 2013).
Paraphrasing, another effective and essential skill, enhances the therapeutic bond
(Vernon & Davis-Gage, 2018). Paraphrasing is not just parroting what the client has
said; rather, it is “feeding back to the client the essence of what has been spoken”
(Cooper, 2014, p. 45). When paraphrasing, it is important to check with the client:
“Am I hearing you correctly?” Giving a young client feedback in the form of clarification and paraphrasing also helps to confirm the counselor’s understanding and
conveys unconditional positive regard to the client (Kress et al., 2019).
Counselors should also be aware that sometimes a child or adolescent needs time
to sort out what has been said. At these times, silence can be useful. Young clients
may use the time to consider their response to a prompt or to feel more comfortable (Broderick & Blewitt, 2015; Headley, Kautzman-East, Pusateri, & Kress, 2015).
Silence also allows the counselor to consider what has been said and indicates that
the client is free to speak. Counselors need to monitor their “talk time” to ensure
that their speech and pacing are helpful to children who need assistance expressing
themselves. Some counselors find it useful to recall the acronym WAIT (Why am I
talking) when working with young clients (O’Rourke, 2015). Oftentimes, counselors
jump in too soon in an attempt to be overly helpful by rescuing the client. Or, they
may jump in too soon and try to take control of the session, thus making the client
feel uncomfortable. By “WAITing,” counselors can consider what they could ask
that would help them better understand what the client is saying.
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Another essential skill is reflection of feelings and meaning. Reflecting feelings
helps clients become more aware of their emotions, develop greater self-awareness,
and facilitate self-disclosure (Cooper, 2014). “It sounds like you feel anxious about
your upcoming test; am I hearing you right?” Reflecting feelings also enhances the
development of accurate empathy. When young clients need help finding words to
describe feelings, comments like these can help:
•
“That sounds really confusing.”
•
“It sounds like you might be feeling a little scared? Is that right?”
Reflection of meaning helps clients go deeper and work through their thoughts
and feelings. Asking something as simple as “What does that mean to you?” can be
very powerful (Vernon & Davis-Gage, 2018).
Summarizing is another important skill that can be used at the beginning of the
session to review work from the last session. For example, “Last time you were here
we were talking about your relationship with your parents. Is that still something
you’d like to discuss today, or is there another issue?” Summarization can also be
used at the end of the session as a review: “Can you briefly summarize what we
worked on today?” Summarizing helps the client feel understood, promotes client
self-understanding, and provides clarification for the counselor. For instance, “Let
me summarize what you just said. You said you failed your test, got grounded as a
result, and now refuse to speak to your parents. Did I get that right?” Summarization
is also useful when clients are rambling or are confused or when they are discussing
unrelated ideas.
USING “PROCESS” QUESTIONS
Process-oriented comments and questions, which look at internal and external processes, are important when dealing with awkward moments, revelations, expression
of intense feelings, moments of insight, counselor “error,” and silences. Processing
also provides an opportunity for the young clients to articulate emotions. According to Peterson (2011), anything can be “processed” (p. 10). Examples of processing
questions include the following:
•
“How did that feel for you to make that big statement?”
•
“After all that hard work, how do you feel now?”
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Processing punctuates moments in the counseling relationship. It also can be used
to stop long narratives and reestablish the focus on feelings or a presenting issue,
as in this instance: “I’d like to put a period at the end of what you’ve told me so far.
I can see that it was upsetting to talk about what happened. What were you feeling
when you told me that?”
OTHER WORDS OF WISDOM
How should counselors deal with clients they know or suspect are not telling the
truth? Should they or should they not offer advice? How can counselors “talk” to
children in language they can understand? These important topics will be addressed
in this next section.
FACT OR FICTION?
Counselors also need to be aware that young clients are usually not as forthcoming
as adult clients and they may distort the truth, for various reasons. When children
tell extraordinary stories, counselors wonder if they are meant to gain attention or
sympathy (Henderson & Thompson, 2016), impress the counselor, or reflect what
the client wishes were true. Directly challenging a statement or story may interfere
with a trusting relationship, and all or part of a story might actually be true. One
strategy is to use immediacy—offering a personal reaction to the comments by
saying, “That story confuses me. It seems like a strange thing to happen. I’ll have to
think about that one.” A response like this gives the child a chance to alter the story
while avoiding a direct challenge. Other possible responses could be, “Which parts
of that story do you think I should think about the most?” “I would like you tell me
more about that”; “I’ll bet some people might think that was strange for someone
your age.” These responses offer an opportunity for the client to expand or retract.
GIVING ADVICE
A common misconception is that counselors are advice-givers. Especially with
young clients, it is tempting to offer advice, and children often expect it. However,
Henderson and Thompson (2016) urge counselors to resist the temptation. In their
opinion, it is preferable to believe in young clients’ worth and assume that given
the right conditions, they can make good choices themselves. Instead of giving
advice, they recommend that counselors “use their skills and knowledge to help
clients make responsible choices on their own, and in effect, learn how to become
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their own counselor” (p. 92). These authors warn against creating dependency and
over-conformity by encouraging them to rely on adults to make decisions for them.
There are times when giving advice may be warranted, but it should be done subtly.
For example, if an underage teenager is drinking a beer in a public place where he
could get caught, the counselor might casually say something like the following: “I
understand that you want to hang out with your friends and drink, but since they
are of legal age and you aren’t, I’m wondering if you have carefully considered the
consequences? Because if you really think about what could happen, you might
decide that drinking in public is not such a good decision.”
Jacobs and Schimmel (2013) take the position that while a counseling session should
not be about advice giving, there are times when it would almost be unethical not to
give advice in certain circumstances. For example, if an adolescent storms into the
counseling office and is out of control, yelling about how the coach discriminated
against him and he is going to confront him, the counselor might advise the client
to get his rage under control so that there is less chance of negative repercussions.
Jacobs and Schimmel stress that giving advice should be done cautiously and that
counselors should not give advice that reflects their own values or morals.
As a general rule, it is preferable to let clients come to their own solutions, depending on their ability to do so, because when they feel in charge of their own growth,
they are more likely to find their own strengths and strategies to use independently
in the future. Counselors can empower young clients by affirming their strengths
and stepping back periodically to explain to the client “what just happened,” while
minimizing the counselor’s role. For example, the counselor might say this: “I am
really impressed with the decision that you made. It seems like you carefully considered your alternatives and also the consequences. Good for you!”
“LANGUAGING” WITH YOUNG CLIENTS
Kress and colleagues (2019) make important suggestions about communicating
with children and adolescents. With younger children, it is very important to use
concrete language and short sentences. Play, toys, and art activities are also good
because children may be more likely to express themselves through these mediums
if their verbal skills are lacking. As children advance in age, their verbal and written
expression skills will mature accordingly. In fact, some young clients develop adultlike advanced vocabulary, but counselors should recognize that brain development
and reasoning skills are probably not similarly advanced. Therefore, although it is
easy to assume that verbally precocious clients have a deep conceptual understanding
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of adult issues, this assumption may be inaccurate. Counselors should rely on basic
listening skills (e.g., clarifying, paraphrasing, and summarizing) to understand
clients’ perceptions and experiences.
THE COUNSELING PROCESS
As previously noted, children and adolescents are not always on board with counseling,
especially if they have been referred by others. School counselors have an advantage in
that they often know many students who are referred or self-refer, but a clinical mental
health counselor is starting from scratch. So, what do you do after you say hello? From
a procedural standpoint, you must deal with informed consent and confidentiality,
but in working with this population, we strongly advise you to first develop rapport.
According to Kottler (as cited in Meyers, 2014), “[W]ithout the foundation of a constructive relationship, anything else that we do isn’t going to work very well or last
very long” (p. 34). We will first discuss rapport building and suggestions for dealing
with resistance and reluctance, as well as the counseling process with young clients.
Ethical issues and confidentiality will be addressed later in the chapter.
ESTABLISHING RAPPORT
Paying attention to the counselor-client relationship is extremely important when
working with children and adolescents, particularly when they may be guarded or
defensive or have little knowledge about the counseling process (Land et al., 2017).
Young clients may initially see the counselor as just one more disciplinary authority
figure, especially if an adult has made the referral. When a child is troubled and
reluctant, the “joining” process may be slow, and it may take one or more sessions
to forge a trusting, unconditional relationship with a child in whose world adults are
perhaps highly reactive, conditional, unpredictable, critical, or even abusive. Helping children learn that a trusting relationship is possible, helpful, and satisfying is
a worthy goal in itself, possibly even a corrective emotional experience, which may
help them trust and feel valued across a variety of settings (Besler, 2017). According
to Sommers-Flanagan and Sommers-Flanagan (2007), an essential part of rapport
building is for counselors to demonstrate integrity by following through on promises
and behaving in ways that show they are thoughtful, considerate, and consistent.
With young clients in particular, counselors focus the first session (and more if
necessary) on becoming acquainted. Children are often more sensitive than are
adults to others’ feelings and attitudes and intuitively know who they can trust
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and who will be understanding and supportive (Henderson & Thompson, 2016).
Rapport-building strategies can help to build a working alliance—chatting about
hobbies, activities, and pastimes, showing genuine interest and concern, and allowing
the client to select an activity to engage in, for example. Fidget toys, stuffed animals,
or coloring books may also help to break down defenses and increase comfort (Kress
et al., 2019; Ray et al., 2013). Read the Dialogue Box sidebar, which illustrates a brief
exchange between a counselor and a young client. You might find that beginning a
session in a similar way will help you build rapport.
DIALOGUE BOX
COUNSELOR: Hi Jeremy! Welcome to this space where we will spend
our time together. In here you can express yourself in many different
ways and share anything you’d like. Sometimes you’ll choose our
activity for the day and sometimes I will. Other times we can decide
together. Let’s get started!” (gesturing toward a table containing
sensory toys and manipulatives)
CLIENT: (Reaching toward a toy) I’d like to play with this fidget spinner!
COUNSELOR: That looks fun! While you’re doing that, could you
tell me a bit about yourself that will help me think of some other fun
things we can do together? For starters, what’s your favorite activity
in the whole world?
Jeremy, 10-year-old referred for ADHD symptoms
In addition to the suggestions described to help develop rapport, counselors should
consider using specific rapport-building activities such as the following. It is beyond
the scope of this chapter to describe more than two, but you can consult More What
Works When with Children and Adolescents (Vernon, 2009) for other ideas.
•
Walk the Line. Put a strip of masking tape on the floor and label one end
“like me” and the other end “not like me.” Read several characteristics, such
as favorite subject is math, thinks school is cool, likes doing homework, more
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of a leader than a follower. Invite the client to stand on either end of the line
and then discuss why he or she chose that position (Vernon, 2009, p. 32).
•
Pick Up Straws. Prior to playing the game, put sentence stems inside plastic
straws, such as something you don’t know about me is, something that makes
me laugh is, the best thing about being my age is. The object is to pick up one of
the straws (placed randomly on a flat surface) without moving another straw.
The counselor and client take turns picking up the straws, taking the slip out
of the straw, and finishing the sentence (Vernon, 2009, p. 25).
Setting Up the Physical Space
Another way to facilitate rapport building is to create an environment in which
young clients feel comfortable. The counseling office should be cheerful and contain
furnishings and developmentally appropriate activities for clients of all ages. The toys
should meet a variety of interests and promote exploration and creative expression
(Kottman, 2011). Also, children respond best when the counselor is at their eye
level, and a variety of seating options can facilitate that. For example, young clients
should be able to plant their feet on the floor, and counselors should not sit behind
a desk (Kress et al., 2019). There should also be areas for play and artistic expression
to help engage young clients in the counseling process.
RESISTANCE AND RELUCTANCE
Discussion of resistance is usually multifaceted. According to Kress and colleagues
(2019), “[R]esistance is a term commonly used to describe clients who have low
motivation” (p. 76). However, when working with children and adolescents, resistance should be conceptualized differently, for several reasons. First, young clients
are usually not self-referred and they may have no idea what counseling is or why
they need it, so it makes sense that they may be reluctant to engage in something
unfamiliar. Second, they may think they did something wrong or that there is
something wrong with them (Vernon, 2009). Third, they may worry that their
friends will make fun of them or dislike them if they are going to counseling. In
addition, they may wonder what to say or if the counselor will tell others what they
said (Henderson & Thompson, 2016). For these reasons, counselors must be warm,
supportive, empathic, caring, and nonjudgmental. If counselors exhibit these characteristics and do a good job establishing rapport to develop a strong therapeutic
bond, overcoming resistance may not be an issue at all.
Read about a resistant client’s experience in the sidebar.
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VOICES FROM THE FIELD—CLIENT VOICE
My grandfather sexually abused me for years. I hadn’t talked about it with anyone
until my parents made me go to counseling because I was acting out. I was really
mad and at first I didn’t want to talk about it, but my counselor seemed really
supportive and I finally disclosed the abuse to her. It was kind of like the start of a
new me—a new life. After that I wanted to tell my story so that other kids would
want to speak up about what happened to them. My counselor helped make that
happen and now I feel so much better.
—16-year-old female client
Before conceptualizing client behaviors as resistant, counselors are encouraged
to examine the function of those behaviors, as well as their own rapport-building
skills. In some cases, inexperienced counselors may be quick to label young clients
who are unwilling to share information about their family, for example, as resistant
or reluctant. In these moments, counselors’ lack of cultural competence or their
ability to develop a healthy working alliance with various populations may in fact
contribute to the problem. Seeking supervision and consultation that affords counselors opportunities to examine their own values, biases, and blind spots is essential
in addressing the issues of resistance and reluctance.
Several scholars offer ideas and suggestions for working with resistance, all of
which contribute to developing good rapport. Holliman and Foster (2016) note that
exhibiting authenticity at the onset of the relationship is a first step toward addressing impasse. Armstrong, Brown, and Foster (2015) suggest providing opportunities
for young clients to communicate in less direct and more concrete ways, such as
with sand tray or play therapy, to mitigate perceived threat. Peterson (2011) offers
structured exercises as a way to help move the counseling relationship forward
when resistance occurs. Malchiodi and Crenshaw (2017) suggest gaining the young
client’s commitment to change through indirect confrontation with puppets, media,
or stories; through paradox and reframing; and through modeling and role-plays.
With resistant adolescents, an effective and empowering strategy to promote
client autonomy, create emotional safety, and emotionally join with the client is
to acknowledge and “go with” or “roll with” the reluctance (Sommers-Flanagan &
Sommers-Flanagan, 2007). This strategy is illustrated by the following statement by
the counselor: “Boy, I really hate it when people try to make me do things I don’t
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want to do. I remember that my parents made me take music lessons and I really
resented it.” Also, remember that sometimes young clients simply do not feel like
talking or don’t have anything to discuss (Henderson & Thompson, 2016). Therefore,
counselors might use checklists or open-ended sentences to initiate conversation. For
example, when working with a resistant child with behavior problems, the counselor
can invite the client to finish sentences, such as “If I misbehave, adults …”; “When
I misbehave I feel … .” Or, a short checklist that the client responds to with yes,
no, or sometimes can be developed: (a) I like how I behave; (b) I feel I control of my
behavior, etc. These strategies are usually perceived as non-threatening and may
help resistant clients open up to the counselor (Vernon, 2009). In general, counselors
need to evaluate what is happening when sessions become blocked and whether a
lack of skill or lack of planning may be contributing.
Parents, too, may demonstrate resistance, but it is important to involve them because
they are the conduit between the counselor and the young client (Henderson &
Thompson, 2016). Nevertheless, parents may object to their own involvement in the
counseling process or deny connections between their own issues and their child’s
presenting problem (Kottman, 2011). Regardless of the challenges of working with
parents, counselors must recognize that in working with young clients, the parent-counselor relationship is undeniably present and can provide a critical support
as young clients experience individuation (Christian, Perryman, & Torey, 2017).
INTAKE AND ASSESSMENT
The intake and assessment process may vary based on context and role (e.g., school
or clinical mental health counselor). Assessment is warranted for accurate case conceptualization and effective strategic planning (Swank & Mullen, 2018) and begins
the moment the counselor acquires information about the client by reviewing a
file, meeting with the child, or discussing client needs with a teacher or parent.
In the school setting, observing the client in the classroom, on the playground,
or in the cafeteria is very helpful. Counselors should use a collaborative approach
when considering how to obtain records that will accurately reflect the current
functioning of a client (Moss, et al, 2017). Generally speaking, when assessing
problems, counselors must take into account the clients’ age, developmental abilities, culture, and context. This information helps them determine how to plan
for client treatment.
In a school setting, young clients might self-refer or be referred by a teacher or other
school stakeholder. After identifying the presenting problem, school counselors may
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contact parents and teachers to learn more about how they see the child in various
contexts and to gather more details about the presenting problem. This collaborative,
systemic method is essential in making course of care decisions regarding the young
client. Collaboration also occurs between school and mental health counselors, so
if clients are of school age, community mental health counselors will most likely
ask parents or caregivers to sign a release of information giving them permission to
request pertinent information from school records, including educational or psychological tests. In school settings, counselors typically have access to school records,
but they also may request that parents/caregivers sign a release of information to
allow them to communicate with the mental health counselor or others involved
in the young client’s case.
The intake process in mental health settings may differ from the intake process
in school settings. For mental health counselors, the intake and assessment process
often begins with a telephone conversation with parents to learn more about the
reason for referral. Next, a face-to-face meeting with the young client or the client
and parents or other family members is scheduled (Sommers-Flanagan, 2016). At
this meeting, the counselor garners informed consent and additional intake information pertinent to the reason for referral. Checklists may be helpful in guiding this
process (Kress et al., 2019). The intake process may involve one or several sessions,
depending on the counselor’s orientation and whether other members of the child’s
family are also interviewed. The importance of a nonjudgmental posture on the part
of the counselor cannot be overstated.
Caregiver Information
The process just described is often conducted directly with parents/caregivers, particularly in clinical settings. In the school setting, a counselor may invite parents to
share concerns and pertinent developmental information during conference time
and in-person or phone discussions or by filling out a questionnaire and returning it to the school. After gathering this important data, the counselor might ask
the parents what they expect from the counseling experience for their child and
whether they have had counseling experiences themselves. The counselor should
explain that children might not experience counseling in the same way adults do
and suggest how the parents can explain to their child what to expect in counseling.
For example, it might be helpful for parents to let their child know that sometimes
it is good for children and adolescents to have their own special time with a trusted
adult who knows how to listen and understands the many challenges that young
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people face. Parents may also want to convey to their child that they have already
met with the counselor so that the child knows the counselor is someone who can
be trusted. For young children, books may help caregivers find appropriate words
to explain the counseling process to children. Two to consider are A Terrible Thing
Happened (Holmes, Mudlaff, & Pillo, 2000) and Do You Have a Secret? (Let’s Talk
About It!) (Moore-Mallinos, 2005).
By signing appropriate permission forms, parents allow school and clinical mental
health counselors to share pertinent assessment information and case details to help
all stakeholders support client development. For example, documentation related to
multi-tiered systems of support (MTSS) or response to intervention (RTI), Section
504, individualized education plans (IEP), and/or school records (e.g., grade and
attendance reports) may be helpful information for school counselors to share with
clinical mental health counselors. With permission, school counselors may also
share personal observations about the client in the school setting, such as how he
or she relates with peers and adults in the school environment and how he or she
performs academically.
Likewise, as clinical mental health counselors proceed with their assessment,
they might exchange relevant information with school counselors to help them with
case conceptualization and intervention planning. They might share information
regarding clinical gains or setbacks occurring outside of school, which helps the
school counselor better understand how to best support the child.
During assessment, counselors need a clear purpose, asking themselves, “What
information will help me better understand and serve this client?” With this
question in mind, counselors can identify appropriate assessment procedures.
Drummond, Sheperis, and Jones’s (2016) four overarching purposes for assessment
can be helpful:
•
Screening: Utilized to provide preliminary data to assess evidence of risk
factors for a particular mental health concern or need
•
Diagnosis: A process by which clinical mental health counselors utilize the
Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association [APA], 2013) to classify and diagnose a client’s presenting
problem. In schools, counselors may collect and disseminate MTSS/RTI data
to other school-based practitioners to determine DSM-5/ICD-10 codes that
may contribute to diagnoses for special educational eligibility
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•
Planning: A collaborative effort in which the counselor considers all available
data, conceptualizes the client’s case, and, with the client, decides on a course
of action
•
Evaluation: The process of determining intervention effectiveness/progress
toward goals
These purposes of assessment are met through three primary methods (Swank
& Mullen, 2018): tests (structured client responses utilizing a variety of formats),
interviews for the purpose of sharing relevant information (between counselor and
client and other stakeholders), and observations (of the client in relevant contexts
while tallying the frequency, intensity, and duration of specific behaviors).
Client Information
Once a young person makes it to counseling, there are many ways counselors gather
information. Most counselors choose to involve young clients in this process, knowing that there is likely additional information that is known only to the clients
themselves. Regardless of whether clients are willing to share this information at
the onset of counseling, counselors may introduce topics as a way to plant seeds for
continued dialogue. They may choose to use the intake process to gather information related to previous or current challenges the young client is facing, significant
relationships, or school experiences. This information can be used to further explore
topics throughout the counseling relationship.
Gathering More Information
When clients are referred by someone knowledgeable about the client’s case, the
counselor can acknowledge whatever information the referral source has provided
and measure the client’s readiness to discuss it (Henderson & Thompson, 2016).
Sommers-Flanagan (2016) recommends asking the parent, teacher, or other referring
person to provide one or two positive attributes about the child that the counselor
can share in the rapport-building phase. A less direct approach allows the child or
adolescent to explain the reason for the referral, which may be different from that
of the referring adults. However, since young clients often have no idea why they are
in counseling, it is often more effective to say something such as, “Your teacher said
you are having trouble completing your homework and thought maybe we could
work together to figure out some strategies that might be helpful.”
In clinical mental health settings, collecting a biopsychosocial history offers a comprehensive way for counselors to gain important background information that was
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not presented during the intake or original assessment process (Lenz, Cade, Parker,
Klassen, & Schmidt, 2017). Elements of a biopsychosocial history include demographic
information, presenting problem, family history, medical and health history, mental
health history, and other relevant information. Although school counselors may also
utilize a biopsychosocial approach to gather additional information, their abilities to
obtain comprehensive information in a traditional session format may be limited by the
time constraints. Instead, school counselors may lean more toward using brief empirically supported assessments such as the Session Rating Scale (SRS) (Johnson, Miller, &
Duncan, 2000), the Outcome Rating Scale (ORS) (Miller & Duncan, 2000) and/or their
child-version equivalents. According to Murphy (2008), these are important assessments
that can help counselors obtain up-to-date information specific to client progress.
School counselors in particular may find it helpful to use the BASIC ID model,
developed by Lazarus (2008) and adapted for children by Keat & Guerney (1980).
Keat & Guerney’s HELPING model is as follows:
•
H = general health information, including diet and sleep habits, any medications, substance abuse issues, etc.
•
E = emotions/affect; how does the client feel and how does he or she
express emotions?
•
L = learning/ school; academic performance, study habits, learning disabilities, etc.
•
P = personal relationships with family, friends, teachers, etc.
•
I = image of self; self-worth, personal strengths and weaknesses, interests
•
N = need to know; skill deficits (cognitive, emotive, behavioral)
•
G = guidance of actions; behaviors and consequences
This model is very comprehensive and excellent to use in collaboration with school
personnel, parents, and the client. The first step is to gather information for each component of the model. For example, the counselor might meet with the client and learn
that he or she has conflicts with his or her friends. In meeting with the parents, the
counselor learns about the child’s health, and teachers can provide information about
school performance. Specific interventions can be developed to address each modality
of concern. Teachers, parents, and the counselor may all be involved in implementing
interventions with the client, and the counselor coordinates periodic meetings with
the adults as well as the client to assess progress and re-evaluate the interventions.
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DEVELOPING INTERVENTIONS
Careful planning, design, implementation, and evaluation of interventions are
important to the integrity and success of the counseling process (Ziomek-Daigle,
2017). After the assessment and intake process, the counselor and client work together
to identify goals, and then the counselor plans interventions to help the client meet
these goals. In designing interventions, it is also important to be aware of unsuccessful previous interventions, the counselor’s skills, the client’s developmental/ability
level and learning style, as well as cultural considerations and time constraints. As
interventions are implemented, the counselor assesses the efficacy of the interventions and makes adjustments accordingly (Swank & Mullen, 2018). Throughout this
intervention-assessment loop, the counselor uses what he or she has learned about
the client, pays attention to underlying themes, and helps the client gain insight and
skills to facilitate goal attainment. The client’s presenting problem and needs interact
with the counselor’s theoretical orientation and experience to inform the counselor’s
choice of intervention (Haskins & Mingo, 2017). As stressed throughout this book,
interventions for young clients need to be engaging and creative. Talk therapy by
itself is not effective with this population (Vernon, 2017).
Creative Arts Interventions
Interventions implemented during the counseling process may encompass a wide
variety of developmentally and culturally appropriate approaches, including play
therapy, bibliotherapy and cinematherapy, therapeutic writing, music, art, and
structured experiences. Many specific examples are described in chapter 3 and
throughout the book. The following list provides additional suggestions:
1.
Metaphors
a.
My Invisible Suitcase (Cook, 2013, p. 24) is an activity related to the metaphor that people carry an “invisible suitcase,” which impacts how they
think, feel, and act. This activity or related activities can promote empathy
for self and others.
b.
The metaphor rollercoaster friendships is a good metaphor that helps young
clients understand common interpersonal struggles.
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2.
3.
4.
Music
a.
Ask adolescents to find songs to help them cope with specific problems or
see things from another perspective. For example, if teens have a problem
with a romantic partner, have them find a song that can help them find
solutions to that problem.
b.
Ask an adolescent client to create a musical autobiography: a playlist of
songs that represent the adolescent’s sense of self. Ian Levy (2012) provides
additional ideas about how to use this specific genre to build the therapeutic
alliance and promote client self-expression.
Bibliotherapy and cinematherapy
a.
Literature can be invaluable for young clients. Whether you use short children’s stories such as My Mouth is a Volcano (Cook, 2008), Cliques Just
Don’t Make Cents (Cook, 2012), or a novel appropriate for adolescents such
as Wonder (Palacio, 2012), literature helps clients realize that they are not
alone in their experiences.
b.
Dove Evolution, on YouTube, is a good conversation starter about the impact
of media on body image. YouTube is an excellent resource for information
as well as entertaining media selections.
Games
a.
Adapt the game Concentration to various topics by developing cards such
as “It’s important to me that my friends”; “One of the best ways to handle
friendship conflicts is”; “I think good friends should.” Make two cards per
set and place them randomly on a flat surface. Each player turns over two
cards, and when a match is made, players respond to the sentence stem
(Vernon & Barry, 2013, p. 16).
b.
Let’s Bowl! This is an engaging game for young clients that requires a plastic bowling set. Make cards to match each of the pin colors, tailored to a
specific client problem. When clients knock down pins, they pick a card
matching the color of each of the downed pins and respond to the question
(Vernon & Barry, 2013, pp. 17–18).
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5.
6.
Role-Play and Drama
a.
By acting out various roles and/or asking the counselor to take on hero
or villain personas, children can often communicate different emotions,
experiences, and power differentials (Kottman, 2011).
b.
Gladding (2011) suggests a family puppet interview in which children create
stories about their family using puppets.
Art
a.
Use an art activity to facilitate career decision making. Have adolescents
find or draw pictures or take photos of career options, then identify what
they know and need about each one. They can also identify pros and cons
of each option (Vernon & Barry, 2013, pp. 153–154).
b.
Draw around a client’s body and ask him or her to draw pictures, write
words, or put Band-Aids on parts of the body where he or she feels hurt
or sad (Lowenstein, 2006, p. 69).
Structured Exercises
Structured exercises (Peterson, 2011) can be effective with all children and adolescents, but they are especially helpful with reluctant or non-verbal clients. Counselors
can overuse and abuse structure, but pencil-and-paper activities such as the following have great potential for building trust, eliciting information about ability and
development, and helping shy and unassertive young clients find their words:
1.
Sentence stems: “Something that is very special to me is …”; “I’m probably
most myself when I …”; “I can imagine myself someday …” (Peterson, 2011,
pp. 21–22).
2.
Checklists: Related to a specific problem, such as the “Am I Stressed” checklist,
where adolescents check whether they experience symptoms of stress a lot, a
little, or not at all (Vernon, 2009, p. 146).
3.
Story starters: Make up a story that is similar to the client’s problem, with “fill
in the blanks” to which the client can respond. For example, if a client has
problems with anger, write a story about an angry fictitious girl: Annabelle was
always angry because————; and when she got angry she————. (Vernon,
2009, pp. 204–205).
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4.
Advantages-disadvantages list: “This sounds like tough decision. Why don’t you
make a list of the advantages and disadvantages of attending this university?”
5.
Age-appropriate decision-making dilemmas: “You are at the mall with your
friends and you see one of them take a video game and sneak it in her backpack.
Do you tell on your friend or not?” (Vernon, 1998, p. 243).
6.
Rating scales: Have clients rate things on a 1–10 scale, such as how well they
think they do in a specific class, how well their family interacts with each other,
etc. Ratings scales can be developed for any topic (Jacobs & Schimmel, 2013).
7.
Movement continuums (could be done on paper as well): On a scale of 1 to 10,
move physically to where you’d rate yourself for each statement, from 0 (not at
all) to 10 (a lot). Examples as related to learning styles could include “I learn best
when I like the teacher”; “I am easily distracted in class” (Peterson, 2011, p. 61).
Developmentally appropriate activities such as these can encourage self-exploration
and can be used throughout the counseling relationship to raise clients’ self-awareness and assist in problem solving.
TERMINATION
The process and therapeutic benefit of termination varies greatly depending on the
nature of the termination (e.g., family relocation, financial/third-party-payer challenges, custody issues, or because the client is ready to move on). Regardless, the
counseling relationship is often a powerful experience for young clients and they
may become anxious as the counseling process draws to a close. If children have
experienced change an upheaval that may have resulted in abandonment, terminating counseling may be especially difficult. Therefore, the counselor should prepare
them for the end of counseling in advance of the final session whenever possible
(Somody, 2007). The counselor should help clients process feelings associated with
ending and should reassure them that they will remain in the counselor’s thoughts.
By doing so, the counselor communicates that the counseling process has been a
significant experience and the client has been worthy of it. Kress and colleagues
(2019) point out that emotions associated with loss, such as agitation, anger, and
anxiety, are normal reactions to termination and should be explored to determine
if termination is premature or if more processing is needed, particularly when termination is initiated by the counselor.
When both client and counselor will remain in proximity and the counselor will
be available, the client can be made aware that future counseling can be arranged
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if needed. Based on the client’s progress in counseling, the counselor can make
predictions about continued success and potential developmental challenges—the
latter to prepare the client for “normal stumbling.” Progress made during the sessions
can be celebrated, with the counselor noting what the client did to accomplish that
progress, and the counselor-client relationship can be validated. The counselor can
model expression of genuine feelings about terminating a relationship and can also
model saying good-bye:
I’ve really enjoyed being your counselor! You have worked really hard. I’ll
remember you as having lots of interesting parts that go together to make
someone really beautiful—like pieces of cloth that make a quilt. Some are
velvety-soft, some rough and nubby, some in between. I’ve seen lots of
different pieces in you. What will you remember from our time together?
When concluding counseling, counselors may have unsettling thoughts and feelings, including about endings and loss—especially when clients are young. These
feelings arise because the counselor knows that the child or teen may continue to
be vulnerable in a complex and troublesome environment. The caring counselor
consequently may worry about the loss of support for the child. Helping professionals need to monitor themselves during these transitions, validating their own
feelings and needs and paying attention to boundary and dependency issues. In
some cases, counseling can be phased out gradually, perhaps by increasing the
length of time between sessions. Counselors may schedule occasional “check-up”
visits to monitor progress.
REFERRALS
Humans are multidimensional, and counselors use their skills to conceptualize
clients’ needs, including advocating for care beyond the counselor’s abilities and
expertise (Goodman-Scott, Cholewa, Koch Burkhardt, & Burgess, 2017). In some
cases, counselors may suggest additional concurrent services, such as referrals for
consultation to child and adolescent psychiatrists, neurodevelopmental pediatricians,
and occupational therapists (Gysbers & Henderson, 2012). In other cases, after careful consideration of the scope of the problem, responses to current interventions,
and what might be best for the child or teen, a counselor may determine that in
order to meet a young client’s immediate needs, a referral to other services, such
as substance abuse or mental health facilities, eating disorder in-patient treatment
programs, social services agencies, or residential treatment centers, is necessary.
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The counselor is responsible for organizing information to ensure a smooth transition and to provide parents or caregivers with accurate information about services
offered at the referral site.
ETHICAL AND LEGAL ISSUES
According to the ethical codes of the counseling profession, counselors must promote
autonomy and balance their desire to do good (beneficence) with their intention to
do no harm (nonmaleficence) (ACA, 2014). These ethical standards include helping
young clients to feel a sense of ownership in their sessions, conceptualizing their
needs appropriately, and considering the various systems that may be affecting their
lives on a daily basis. With these principles in mind, counselors can feel challenged
when the course of treatment stalls. Some of these barriers to client progress include
client resistance and reluctance. It can be helpful to try to anticipate any experiences
that may trigger one to abandon these basic ethical responsibilities.
Counseling practitioners working with children and adolescents should consult
state law and draw on their respective professional organization’s code of ethics and
the American School Counselor Association (ASCA) Ethical Standards for School
Counselors (2016) for support. Because children have protected status, counselors
working with them must remain legally and ethically informed. With a client’s age
and maturity in mind, counselors should regard children as partners in the counseling relationship, informing them about their rights to participate in setting goals
and planning treatment, to expect privacy and feedback, and to be able to refuse or
end treatment (Corey, Corey, Corey, & Callanan, 2015). Counselors must also recognize that a number of challenges to this partnership are inherent in the relationship.
First, as minors, children are not legally considered responsible for themselves
because they do not have sufficient understanding or the ability to make informed
decisions independently. This limitation applies to decisions about whether to accept
or refuse various therapeutic interventions. Second, young children are not considered legally competent because they have not reached the statutory age, which is
state dependent. And, as previously noted, children do not often come to counseling
initially on their own accord, so it may be more challenging to become partners
with this population.
Legally, parents/guardians are responsible for making informed decisions on behalf
of their children. Throughout the therapeutic process, counselors should therefore
facilitate open dialogue with both parties (ACA, 2014; Kress et al., 2019), including
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helping the adults understand various components of the counseling relationship
that promote client growth. Many of these areas are outlined and should be discussed at the onset of treatment with clients during the informed consent process.
INFORMED CONSENT
From the outset of the counseling relationship, it is essential for counselors to engage
in the ongoing process of informed consent (ACA, 2014). In working with minors,
counselors need to make sure that children and parents alike understand the types of
services available, the fees (if applicable), the potential risks and benefits to counseling,
and that written permission will be sought if there is a need to release information to
other professionals (Kress et al., 2019). According to Sori and Hecker (2015), it is best
practice in a mental health setting to include this information in a written professional
services agreement that is signed by the accompanying adult prior to the initiation of
counseling. Most regulatory boards that oversee the practice of counseling in their
states require counselors to file an informed consent document with their respective
board. It is also important to acknowledge that with issues such as substance abuse,
sexual abuse, pregnancy, sexually transmitted diseases, and contraception, or when
the process of gaining parental consent may preclude treatment, minors may be
allowed to consent to treatment without parental knowledge or approval. Treatment
for emancipated minors, emergency treatment, and court-ordered treatment are
also recognized as general exceptions to the requirement for parental consent. The
age at which a child is considered competent to give informed consent varies from
state to state, and counselors are responsible for knowing the laws and statutes of
the state(s) in which they practice.
Successfully navigating the complexities of these challenges is necessary for two
reasons: first, transparency with adults is important for garnering support for counselors’ work with youth, and second, exhibiting openness throughout the counseling
process is essential for building a solid foundation of trust and promoting autonomy
with young clients. While many young clients cannot legally consent to treatment,
one way to support the counseling relationship is to engage children and adolescents
in the assent process.
ASSENT
It is important to include young clients in the informed consent process to some
degree, depending on age and developmental level. Ideally, both minor and parent(s)
consent to treatment. Assent, however, should be obtained regardless of whether the
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child consented to treatment. Assent differs from informed consent in that it involves
sharing information about the counseling process with the young client so that he or
she will understand the services to be provided, the counseling process, the role of the
counselor and the young client, and other relevant information. Counseling should
be explained simplistically to young clients by saying something like this: “As your
counselor, I can help you if you are worried about something or just want to talk about
how you feel. Kids who come to counseling are normal kids who just may need help
making good choices or working through some problems. I will listen to you carefully
so that I can understand what you are thinking and feeling. I’m here to support you.”
As young clients’ chronological age and developmental level increase, so do their
abilities to comprehend the nature and vicissitudes of the counseling process and
each party’s roles, responsibilities, and obligations. To this end, assent and informed
consent can be thought of as existing on a continuum. As the minor clients’ ability
to participate in the information-sharing and decision-making process grows, they
may have increasing voice in the informed consent process.
CONFIDENTIALITY
Confidentiality must be discussed and clarified with young clients and their parents/
caregivers throughout the counseling process. In clinical mental health settings,
counselors may manage minor clients’ privacy and confidentiality rights similar to
how they do this with adults; while in the school setting, counselors may need to
navigate additional challenges (Isaacs & Stone, 2001). In either context, counselors
must honor parents’ legal rights to gain access to their children’s records and manage
their involvement in productive ways. Parental involvement may take many forms.
For example, in schools, a counselor may contact parents to gain information about
the family system and how the parents perceive their child. Alternatively, parents
may contact the counselor for information about their child. In agency settings, this
information is often gathered through the intake process and clarified as needed
during treatment. Overall, counselors should consider how to discuss and manage
confidential information when working with young clients.
Several scholars have discussed confidentiality related to communicating with
a young client’s parents/caregivers. According to the Lloyd-Hazlett, Moyer, and
Sullivan (2017) study, counselors who work with minors often struggle with the
uncertain boundaries of confidentiality and may draw on Hendrix’s (1991) suggestion to choose one of four positions: complete confidentiality, limited confidentiality,
informed forced consent, and no guarantee to confidentiality when working with
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parents. Sori and Hecker (2015) more recently suggest two alternative positions:
mutual agreement and best interest agreement, which each require open dialogue
and trust between the counselor and the parents.
School counselors have particular challenges with confidentiality because school
personnel (e.g., teachers, principals) often request information about children. Because
of this dynamic, school counselors should educate school personnel and parents about
the laws and ethical guidelines governing the counseling profession. Additionally,
counselors must be aware of the Family Rights and Privacy Act (FERPA) enacted
in 1974, which mandates and governs how and with whom educational records are
shared. Based on these mandates, schools (including counselors) may share relevant
information about minors within the educational building on a “need to know” basis
(U.S. Department of Education, 2015). Counselors must use clinical judgment to
help them respond to these extended boundaries with relevant stakeholders. Sharing
information, both in and outside of the school setting (upon written request), should
be performed with care in order to preserve the young client’s autonomy and privacy
as much as possible (ACA, 2014). It is important for school counselors to know that
case notes, which are kept in the counselor’s sole possession and not accessible to
anyone else, are exempt from FERPA mandates. ASCA (2016) recommends that
school counselors keep these records separate from other educational files.
Breaching Confidentiality
All professional associations have ethical codes pertaining to clients’ rights to privacy and client choice about who shall receive information. Within these codes are
significant exceptions that must be articulated to clients, such as duty to warn or
protect; client consent for disclosure; reimbursement requirements or other legal
rules; emergency situations; or when the client has waived confidentiality by bringing a lawsuit (Stone, 2017). Ongoing discussion about the nature of confidentiality
and young clients’ rights to be informed about it and involved with it should occur.
Additionally, regardless of the age of the child or adolescent, confidentiality guidelines should be clarified regularly with clients as well as any involved parents or
caregivers. Even though parents have a legal right to information about their children’s lives, scholars suggest that the following points be highlighted during the
informed consent process (Ziomek-Daigle, 2017):
•
A trusting relationship is essential to effective counseling, and insisting that
information be shared may undermine the relationship and the process.
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•
It is not in the client’s best interest for a counselor to share information, except
when the counselor believes it is necessary to protect the child or others.
•
School-age clients often want their parents to know what they are saying in
sessions, but nevertheless, the client should have the choice regarding what is
shared, except when sharing is necessary to protect them or others from clear
and imminent danger.
•
The counseling process promotes empowerment through choice, and the client
will explore issues and decisions with empowerment and choice in mind.
•
The counselor will help the young client tell the parents what they need to
know, but the parents should recognize that telling or not telling is the young
client’s choice.
•
A joint session, involving counselor, client, and parent(s), is an option, when
appropriate, for discussing an issue.
•
If parents object to any of these points, they may decide not to initiate or to
discontinue counseling, if counseling is not mandated.
Counselors may worry about their decisions regarding confidentiality with and
on behalf of minors. However, most parents are sensitive to their child’s right to
privacy. They accept that they will be informed about general progress, and if there
are safety concerns, such as when an adolescent engages in potentially dangerous
substance use, their child’s safety will be paramount (McWhirter, 2002). Before
working with young clients regarding confidentiality, reflect on your own experiences
with confidentiality by reading the “Personal Reflection” sidebar.
PERSONAL REFLECTION
Have you ever told someone something very personal, thinking that what
you were telling them would be kept in confidence, only to learn that what
you said was shared with others? Have you ever operated under the assumption that you could share some information about one friend with another, only to find out that you should not have shared it? Reflect on your
feelings about having your own confidence broken; did it impact the level
of trust you had with your friend? What do you wish your friend would have
done differently? How did you feel when you learned you shared something
you should not have shared?
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NONCUSTODIAL PARENTS
Non-custodial parents have the same rights as custodial parents unless a court
order states otherwise (Kress et al., 2019). It is important to consider context and
history when communicating with each parent and remember that documentation
is potentially public information (Stone, 2017). Counselors should recognize the
importance of on-going dialogue about confidentiality and its limitations with
young clients and their parents. They should also explain confidentiality in language
developmentally appropriate for young clients’ level of cognitive development and
be sensitive to their concerns about private information being shared with outside
stakeholders. Counselors often struggle to find the right words to explain confidentiality in developmentally appropriate ways. Refer to the “Add This to Your Toolbox”
sidebar for a script that might be helpful.
ADD THIS TO YOUR TOOLBOX
When you first begin to practice as a counselor, sometimes it is helpful to
have a planned script in your toolbox. The following can be used to explain
confidentiality to children and adolescents:
“What we discuss here stays private. If anyone asks me about
what we talk about, I will check with you about whether you
want me to say anything. I will go by what you say. Your parents/caregivers have the right to know about our work so they
can help you, too; if they do ask me for some information, we
can discuss what I will say together beforehand. But one of my
jobs is to keep you safe, so I want you to know that I will have
to tell somebody if I think you might hurt yourself, if you’re
going to hurt someone else, or if I think you are being abused
or hurt or someone is putting you in danger. I’d have to tell
that to someone who could do something to keep you safe.
The law says I have to do that. So, what do you think of what I
have said?”
TAKE-AWAYS FROM CHAPTER 2
As we conclude this chapter, we would like to refer to the vignette at the beginning
of the chapter and share what I (Sarah) learned from working with this client, as
well as a technique I used that I think was effective. As you may recall, Cara was
experiencing anxiety, punctuated by panic attacks and self-harming behaviors.
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The technique of working with Cara to create the collage out of magazines was
ultimately effective because it broke down her defenses and allowed her to have a
creative outlet in which to express her interests. This rapport-building activity became
the catalyst for future self-expression as I learned that using art, writing, and even
essential oils to both express herself and as coping strategies for her anxiety were
important to her progress. One thing I learned from working with Cara is that asking
too many questions while she was creating her collage resulted in her somewhat curt
responses. In fact, I initially thought that this activity was not going to be effective,
as I may have been trying too hard to use it to glean information. It may have been
better to use the skill of tracking to validate her decisions (e.g., “I see that you are
gluing a SlimFast shake in the corner”) so that she felt heard in that moment.
After reading this chapter, you should be knowledgeable about these key points:
•
General considerations when counseling young clients
•
The counseling process, specific to children and adolescents
•
Examples of developmentally appropriate interventions for children and
adolescents
•
The “language” of counseling children and adolescents
•
Strategies for working collaboratively with and on behalf of young clients
•
Ethical considerations as they apply to young clients
HELPFUL WEBSITES
https://suicidepreventionlifeline.org/help-yourself/youth/
https://positivepsychologyprogram.com/
mindfulness-for-children-kids-activities/
Healthychildren.org
https://www.healthychildren.org/English/Pages/default.aspx
DSM-5 Online Assessment Measures
www.psychiatry.org
PRACTICAL RESOURCES
http://www.dhs.pa.gov/cs/groups/public/documents/manual/s_001583.pdf
http://www.who.int/mental_health/resources/child/en/
https://www.anxietybc.com/anxiety-PDF-documents
http://www.selfinjury.bctr.cornell.edu/resources.html
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CHAPTER 3
Creative Arts Interventions
Ann Vernon
LEARNING OBJECTIVES
1.
To identify why creative arts interventions are so effective with young clients
2.
To learn how to use various creative arts interventions in assessment and
treatment
3.
To learn numerous creative arts interventions
U
pon the recommendation of Manuel’s teacher, his parents scheduled an
appointment with me to help Manuel with behavior management. Almost
immediately I realized that trying to get this 9-year-old to focus at 4:00 in the
afternoon would be next to impossible, given that he was literally bouncing up and
down on the sofa and had begun grabbing objects from the toy basket the minute
he sat down. Since this was the first session, I engaged Manuel in a get-acquainted
game that would get him up and moving and perhaps help corral some of his energy.
I explained that he should stand in the middle of the masking-tape continuum on
the floor and I would read some statements to him. If what I read was “a lot like
him,” he would slowly jog to the left end of the continuum and if what I read “not at
all like him,” he would slowly jog to the other end. This seemed to pique his interest
and he responded when I asked if he liked school, had lots of friends, watched funny
movies, loved soccer, and so forth. After playing the game for a few minutes, I asked
him to sit down and we discussed why he was seeing me and how we might work
together to help him learn to manage his behavior so that his parents and teachers
didn’t always have to remind him to sit still, be quiet, and keep his hands to himself.
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Obviously in Manuel’s case, traditional “talk” methods of counseling would
not be very effective nor appropriate. This is the case with many clients, especially
children and adolescents, who process information differently than adults and who
may be unaffected by the counseling process because standard techniques in and
of themselves are inadequate. In reference to young clients, Post (2014) states that
“the usefulness of talk therapy is limited because they often cannot communicate
effectively using words” (p. 49).
As Degges-White and Davis (2011) note, the counseling process has been characterized by predominately verbal approaches that are not sufficient for young clients
who may not be able to express themselves adequately because their vocabularies are
limited, they may be reluctant, or they speak another language. Consequently, practitioners are acknowledging the importance of incorporating creative or expressive
arts interventions into the counseling process to make it more stimulating, enriching,
and meaningful (Neilsen, King, & Baker, 2016). Degges-White and Davis (2011) stress
that “the expressive arts are exceptional in their effectiveness for individuals who
represent a wide array of diversities and differences” (p. 4). These authors also note
that because of their universal nature, they can be used with any client, “regardless
of gender, ethnicity, ability, age, language, cultural identity, or physical functioning”
(Degges & White, 2011, p. 5).
The purpose of this chapter is to identify the rationale for using creative arts
interventions with children and adolescents and to facilitate understanding and
application of the following creative arts interventions: play and games, therapeutic
writing, music, the visual arts, literature, and drama. Specific examples of interventions that can be applied to a wide variety of problems experienced during childhood
and adolescence will be presented.
TOP 12 REASONS FOR USING CREATIVE ARTS
During my many years of practice as both a school counselor and a mental health
therapist in private practice, I became a firm believer in alternatives to the “listen
and nod” approach to counseling because, based on experience, clients left my office
feeling better, but did they actually get better? I wasn’t convinced, since many kept
coming back week after week with the same or similar problems. But when I started
thinking outside the box and developing more creative, hands-on approaches, I
definitely saw good results. I developed the following reasons for using the creative
arts in counseling (Vernon & Barry, 2013):
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1.
Because children and adolescents are often not self-referred, they may be resistant, or as I prefer to think about it, reluctant to engage in the counseling
process because they don’t know what to expect. They may be anxious, unable
to express their thoughts and feelings, or may not trust the counselor. In the
sidebar, read about a resistant adolescent’s experience when her counselor used
a creative arts intervention to help her deal with anxiety.
VOICES FROM THE FIELD—CLIENT
When my parents made me go to counseling because I was so anxious and
couldn’t sleep at night, I didn’t want to go because I didn’t think it would help.
I told my mom that she could make me go but she couldn’t make me talk. So,
during the first session I hardly said a word, but that didn’t really seem to matter
much to my counselor. Instead, she just talked to me about how she had helped
other teenagers with their anxiety and she thought she could help me too. She
gave me a list of things other teens get anxious about and asked if I would be
willing to check off the ones that applied to me. I did that, and then she asked if I
could rank order the list so that what I worried about the most was number 1, etc.
I did this, and then she said that something that had helped other clients was to
talk through each of the worries, starting with the ones that were at the bottom
of the list. She said that after talking things through together, some of her other
clients weren’t feeling as anxious and so they wrote those worries on strips of paper and stuffed them in a balloon, blew up the balloon and let it go—symbolically
“letting go” of the anxiety. She asked if I was willing to try this, so I agreed. I have
to admit that after a few sessions I was a lot less anxious and it was great to “let
go” of some of the anxiety. (Vernon, 2002).
—Brianna, age 16
2.
Another compelling reason to use the creative arts is that the wide variety
of techniques makes it easy to address different learning styles. Counseling
has typically been characterized as an auditory/verbal approach, but that
can be very limiting for those who might be more visual or kinesthetic.
In schools, teachers often refer students to the counselor because they are
experiencing behavior problems in the classroom, and oftentimes this is
because the learning environment is generally geared toward the auditory/visual learner. These students will more likely benefit from a more
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experiential approach, such as playing a game of hopscotch that requires
them to identify effective ways of behaving in the classroom before they
can jump to the next space.
3.
Creative arts interventions are also very culturally responsive. As Gladding
(2016) notes, “The creative arts are truly global and relevant to counselors
from multiple settings and backgrounds” (p. ix). Being culturally responsive
is imperative in today’s world, and it is a well-established fact that clients from
other cultural backgrounds respond well to the creative arts. According to
Gladding (2016), creative arts interventions help clients from all walks of life
develop self-awareness and the ability to relate more effectively with others
through concrete experiences. One of my former colleagues speaks to the
importance of learning about a client’s culture in the sidebar.
VOICES FROM THE FIELD—PROFESSIONAL
Based on my experience working with a Native American adolescent, I found
that it was very important to use her as an “expert” in helping me learn more
about her culture, specifically the rituals that seemed to be the one way that she
found meaning in her life. It was helpful to me to have her share how important
participating in tribal dancing had been to her until she became depressed and
dropped out of these sorts of activities. Having some cultural background helped
me relate to her more effectively.
—Lynne, a social worker in a mental health center
4.
Interventions with younger clients need to be impactful, which characterizes
many of the creative arts interventions. For example, rather than talking
about self-downing with an adolescent, I gave her a sponge and a bucket of
water. I asked her to dip the sponge in the water and used this metaphor to
explain that when she puts herself down, it is like soaking up her negative
aspects, which in turn depresses her. I then showed her that if she gradually
wrings the sponge out by challenging the negative thoughts that either weren’t
true or were overgeneralizations, she would be less depressed. This metaphor
made sense to her and she frequently told me that she was trying hard not
to “soak it up.”
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5.
Another reason for using creative arts interventions with young children is that
they may have difficulty expressing their feelings or articulating their thoughts.
Imagine you are counseling a 5-year-old whose dog just died. Reading a book
such as Saying Goodbye to Lulu (Demas, 2009) can facilitate expression of
feelings and help the child learn effective coping strategies.
6.
Because thinking progresses from concrete to abstract, interventions need to
be concrete so that young clients can understand and apply the concepts. For
example, I was working with a fourth-grader who thought he had to be perfect
because he thought that his older brothers were perfect. During one session,
I asked him to juggle three tennis balls, which of course he couldn’t do. I then
asked him to take these tennis balls home and ask his brothers to do it. When
he came to the next session, he said that neither his parents nor his brothers
had been able to juggle the three balls at one time. This segued into a discussion
about perfectionism and how impossible it was to do everything perfectly.
Phillip kept referring to this experiment when he needed to remind himself
that he could try his best but he didn’t have to do everything perfectly. This
concrete intervention was much more impactful than just talking about perfectionism. Another developmentally appropriate intervention is described in
the “Add This to Your Toolbox!” sidebar.
ADD THIS TO YOUR TOOLBOX!
As you read in chapter 1, children, and even adolescents, are dichotomous
thinkers. Consequently, it is very important to help them learn that either-or-thinking results in emotional problems. I developed the catastrophe
continuum to help an 8-year-old deal with her anxiety about her mother
dying in a car accident. In her mind, her mother would be in a car accident
and die or she wouldn’t have an accident and wouldn’t die. When I worked
with her, I put a strip of masking tape on the floor and at one end, I put an
index card that read “die in a car accident,” and at the other end, a card
that read that there would be no accident and mom wouldn’t die. Then, I
helped her see that there were lots of other possibilities: Her mom could
be in a bad accident and end up with serious injuries but not die, she could
be in an accident and break an arm or leg, she could be in an accident and
have cuts and bruises and the car would be wrecked, and so forth. As we
brainstormed other possibilities, it was obvious that she had not thought of
these and when she did, her anxiety decreased markedly. This intervention
can be used with numerous problems related to dichotomous thinking.
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7.
Anyone who works with children knows that it can be challenging to keep them
engaged because their attention spans are limited. As the case of Manuel at the
beginning of the chapter depicted, interventions need to be motivating and
engaging. Helping Manuel differentiate between positive and negative ways
to manage his behavior was much more effective when I had him toss ping
pong balls into buckets representing positive or negative behavior management
strategies. This intervention definitely kept his attention!
8.
Not only do children have difficulty maintaining attention during the session,
but they also have limited ability to remember the concepts between sessions.
For this reason, creative arts interventions are especially effective. Using metaphors, props, art, games, or music helps anchor the concepts in their heads.
I remember working with a 16-year-old whose girlfriend had not called him
the previous night as promised. He was extremely angry and upset, thinking
that she wanted to break up with him, that she was out with someone else,
and that she didn’t love him. His distorted thinking interfered with his ability to think rationally about the situation, so instead of realizing that there
may have been other reasons that she didn’t call, he assumed the worst. The
“Dialogue Box” illustrates how I used a concrete metaphor to help him learn
to think more clearly.
DIALOGUE BOX
COUNSELOR: I notice that you are looking out the window. Do you
see the bug zapper?
CLIENT: Yeah.
COUNSELOR: So, what happens to the bugs when they hit
the zapper?
CLIENT: They drop dead as soon as they hit the zapper.
COUNSELOR: So, I wonder what would happen if you pretended
that your head is a giant bug zapper and every time you assume
the worst or overgeneralize about things related to your girlfriend
or other issues, you could “zap” these thoughts and check out the
facts before getting so upset. Do you think you could try that?
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CLIENT: Yeah, I guess.
This client not only used the bug zapper to help him deal with
this issue, but the metaphor was so powerful for him that he was
still using it when I saw him a few years later when he was in college
and again after he had just gotten married!
9.
Either due to diversity factors or developmental considerations, there can be
a mismatch if the counselor relies too much on verbal approaches. I remember supervising a school counseling intern who went into a rather lengthy
explanation about making responsible decisions, and it was obvious that the
information was going way over the client’s head and he was tuning her out.
Introducing concepts through drawing, play, or games is recommended as an
adjunct to verbal methods.
10.
Although counseling is a very rewarding profession, it can also be hard work. We
may carry our cases home with us when we get over-involved with clients or we
don’t say no to people who need us, to the point that helping others may mean
hurting ourselves. Burnout is common in this profession, but using creative arts
interventions is a good way to prevent burnout because the counseling sessions are
more meaningful and there is a lot of variety that helps keep the process moving.
11.
Another reason for using creative arts techniques is that they are interactive, which
is very appealing with children and adolescents. I recall working with a teenage
boy who was very quiet, and it was like pulling teeth to get him to talk about
anything. It was quite obvious that he was depressed, but he would not confirm
or deny that. I knew that he was very interested in music, so I asked him if he
would make a music collage of meaningful songs with messages that conveyed
what he was experiencing. For several sessions, we basically listened to music,
but gradually he began to open up and share what he was thinking and feeling.
The music collage helped me understand my client and also seemed to facilitate
his expression of concerns so that we could address the issues more specifically.
12.
By now you can see why creative arts interventions are so appropriate with children and adolescents in particular, but there is another reason to use them—they
are more engaging for the counselor as well as the client! Active listening is hard
work, but if you supplement that with some intriguing interventions, the sessions
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are not only more effective, but they are also more fun! I was working with a
teenager who had major problems with procrastination. During one session I
had her make a list of everything that she procrastinated about, and when the list
was complete, I asked her to lie on the floor face up. I explained that I would read
what was on her list, and for every item I would put a stack of newspapers on her
chest to symbolize how things could “build up” when she put things off. After
asking how she felt about being under this pile of procrastination, I informed her
that she could reduce the pile by identifying something she could think and do
regarding each item on the list. This was a fun intervention and being “under the
pile” really helped this client understand the negative effects of procrastination.
PLAY AND GAMES
According to Landreth (2012), “[T]oys are used like words by children, and play is
their language” (p. 12). Play appeals to youth from all cultures. As Brems (2002) notes,
“Play is perhaps one of the most common techniques utilized by child therapists”
(p. 248). Malchiodi (2005) asserts that toys provide a way for children to “show” what
is happening in their lives. By expressing their feelings and experiences through play,
they learn about themselves, develop problem-solving and socialization skills, act
out confusing or conflicting situations, master their fears (Kottman, 2011), and learn
more effective communication skills. As Henderson and Thompson (2016) note,
play can “enhance normal development and alleviate abnormal behavior” (p. 545).
It is important to distinguish between play therapy and using play and games
to facilitate the counseling process. Play therapy requires extensive training and
certification, whereas these requirements are not necessary when toys and games
are used in the context of a counseling relationship. Although many of the same
toys are used as in play therapy, the process is very different, as will be addressed in
chapter 4. The focus of this chapter is on the use of play and games in counseling.
ADVANTAGES OF USING PLAY AND GAMES
There are numerous advantages for using play and games. In particular, games provide
an alternative way of connecting with others (Gladding, 2016), and because they can
be challenging and thought-provoking, they teach mastery (Vernon & Barry, 2013).
In addition, children can assume responsibility for their behaviors and learn and
practice productive behaviors through play and games (Post, 2014). They can also
act out confusing situations and test reality by trying on different roles and selecting
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solutions (Kottman, 2009). Using puppets as a form of play increases self-awareness,
enhances relational skills, and helps children deal with real-world situations (Desmond, Kindsvatter, Stahl, & Smith, 2015). Another advantage is that play and games
can be used with a wide variety of typical developmental problems, as well as more
serious issues such as grief and loss (Bullock, 2007), chronic and terminal illness
(Gladding, 2016), abuse (Gil, 2006), and trauma (Desmond et al., 2015). Finally, this
approach can be used with individuals, in small groups, and in classrooms.
TYPES OF PLAY AND GAMES
Puppets, dress-up clothes, stuffed animals, dolls and doll houses and other nurturing toys, blocks and Legos, hats, toy vehicles, aggressive toys such as toy soldiers or
dart guns—the list is endless in terms of toys that facilitate expression of concerns
and resolution of problems. A variety of games can also promote awareness and skill
development: board games, movement games such as hop scotch and musical chairs,
card games, or games such as Tic Tac Toe or chess. All these games should be adapted
to the assessed problem. For example, musical chairs is an entertaining yet effective
way to help second graders in a classroom guidance lesson learn more about feelings.
As they move around the circle of chairs to the music, the child left standing when the
music stops picks a feeling card from a basket and reads it out loud, then talks about a
time when he or she felt this way. Tic Tac Toe can be adapted and used to help young
adolescents learn to distinguish between facts and assumptions (Vernon & Barry, 2013),
and thoughts and feelings related to competition can be discussed while playing chess.
WAYS OF USING PLAY AND GAMES
There are many ways to use play and games to enhance the counseling process. Generally, they are used with children between the ages of 3 and 12, although they can also be
effective with adolescents, especially those who aren’t very verbal (Vernon & Barry, 2013).
It is a good idea to ask pre-adolescents and young teens if they would prefer to play a game
related to their problem or discuss their situation so as to not appear condescending.
Rapport-Building
Because games are familiar and non-threatening, they are also an excellent way of
developing rapport, which is essential in working with children and adolescents.
Because children are often referred by others and may be reluctant to be in counseling, it can be less intimidating when they can engage in something other than talk
therapy. One of the games I frequently use with young clients is “Who Are You?”
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The client and I take turns asking the other “Who are you?” and responding with
something descriptive. For example, in response to my questioning, I learned that
9-year-old Rohan likes going to school, eating Biryani and Sambar, and watching
movies. He learned that I like red cars, books, and Golden Retrievers. With adolescents, I often ask them to take three things out of a purse, wallet, or backpack that
represent something they value or that tells something about them.
Problem Assessment
Especially with young children, using toys facilitates the assessment process. Kottman (2011) suggests using dolls, puppets, and family figures for assessing family
dynamics, scary toys to facilitate identification of fears, and toy weapons to assess
aggression. I recall working with a young preschooler who picked a toy telephone
out of the basket and pretended he was talking with his father who hadn’t shown up
as promised for a weekend visit. In a few minutes, I learned a great deal about how
this young client felt about his dad’s broken promises. In using toys and games in
assessment, it is important to pay close attention to the client’s interactions, perceptions, and inhibitions, as well as how thoughts and feelings are expressed.
Games are also very effective in assessment. Playing a board game such as “It’s
Me!” (Vernon, original) engages children in describing aspects of themselves as they
move around a game board and respond to questions on cards that correspond to
the color of the square they landed on. Even middle school students enjoy playing
“Roll It” (Vernon & Barry, 2013), which involves rolling a dice and picking a card
from a pile that corresponds to the number on the dice and relates to the client’s
problem. For example, 11-year-old Astur had learning problems, so questions such
as the following were helpful in gathering more information about her issue: Which
subject is most difficult for you? What is it like when the teacher hands papers back
in class? How do you feel when you try to do something that seems too hard?
Intervention
In using play and games as interventions, it is important that they are easy to learn,
and they are more effective if they are incorporated into the counseling process
rather than being presented at the beginning or end of the session. It is also critical to
develop or select a game or play activity that directly addresses the identified problem.
Although there are some excellent commercially produced games that target specific
issues such as anger or decision-making, you can also adapt more generic games, such
as checkers, to various counseling topics. For example, I worked with an adolescent
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who lacked social skills and he had to identify something that he could say or do to
help him make friends each time he successfully overtook one of my checker pieces.
Making your own games can be even more effective because you can tailor the
game to specific client problems. A few of mine are described in the following paragraphs, and readers are directed to Counseling Outside the Lines: Creative Arts
Interventions for Children and Adolescents (Vernon & Barry, 2013) which describes
63 creative arts interventions that can be used in individual counseling and 21
classroom or small group interventions.
•
Put a Spin on Self-Acceptance—I developed this intervention for an 11-yearold who routinely put himself down. On a piece of tag board, I drew a circle
and divided it into 12 slots (see Figure 3.1). I cut a piece of tag board in the
shape of an arrow and attached it to the tag board circle with a brass fastener. I
explained to my client that when he spun the arrow and it landed on a negative
statement, he could write a more positive replacement statement underneath
it. Writing the statement was useful as we reviewed his replacements and
discussed more about ways to avoid self-downing.
this!
r.
d.
pi
stu
I be s
I can’t d
o
so
can’t
nswe
mb a
t a du
Wha
I’m
Why
I’m
am
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reason me!
e
h
t
I’m
e ga
lost th
mart
er?
I’ll n
s me.
y like
.
it ri
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ser
a lo
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I’m
.
I’m a
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ds.
n
ake frie
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rn
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th
is!
I can’t m
a
t
n’
ever
terrible
d
Nobo
ly.
ug
FIGURE 3.1 Put a Spin on Self-Acceptance.
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•
Jumping Through Hoops—This intervention is an effective way to help
children and preteens learn to overcome frustration when tasks seem too
difficult. For this intervention, you need a hula hoop and a set of frustrating situation cards based on the client’s actual frustrations. Explain to the
client that he or she will draw a card and jump into the hoop that you are
holding in front of the him or her. Once inside the hoop, the client reads the
frustration card and the counselor encourages more self-disclosure about
what is so frustrating about this, helping the client identify thoughts such
as, “It’s too hard,” “I’ll never figure it out,” and so forth. Then the counselor
says that to jump out of the hoop the client must identify something he or
she could think or do that would make this issue less frustrating. The game
continues in this manner.
•
Twist and Shout—This intervention was developed to address problem-solving
and decision making strategies. First, make a twister board using a
flannel-backed tablecloth or an old bed sheet that is divided into 12 to 16 squares
and color coded using large X’s to designate different colors. Then, make a set
of cards that instruct the client how to move, such as “left foot yellow, right
elbow blue”; “right knee purple, left hand green.” Next, make color-coded cards
with typical decision-making dilemmas, such as “Your best friend ignored
you on the school bus this morning. What do you do?” “You ask one of your
classmates if you can play basketball with his group and he says no. What do
you do?” Explain to the client that he or she first draws a movement card and
moves, and then you will draw a dilemma card and read it. After thinking
about it, he or she shouts out a response to the dilemma. This intervention can
be used individually or in a group (adapted from Vernon, 2009).
THERAPEUTIC WRITING
There are many different forms of writing that can be used to help clients develop perspective, resolve life’s difficulties, promote personal growth, and improve emotional
well-being (Gladding, 2016). Writing, which is frequently referred to as scriptotherapy, is an effective self-help approach and can be a very powerful adjunct to the
counseling process, according to Gladding. It may not be as helpful with younger
children who might have limited vocabularies or find writing to be too laborious.
It also may not be the best approach for non-native speakers. However, counselors
can serve as scribes for younger clients and non-native speakers can write in their
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own language. Certain forms of writing may be more helpful than others, so it is
important to determine what is most effective for each client.
Writing, or scriptotherapy, refers to using various forms of writing in a therapeutic way (Vernon & Barry, 2013). Wright and Chung (2001) define writing therapy
as “client expressive and reflective writing, whether self-generated or suggested by
a therapist/researcher” (p. 279). Although we often think of writing as a creative
endeavor, it is much more than that and can include a more structured approach,
such as using activity sheets with questions that help clients clarify thoughts, articulate feelings, and develop skills.
ADVANTAGES OF USING THERAPEUTIC WRITING
Therapeutic writing is very versatile, and there are numerous advantages to using
this approach. Not only is writing cathartic, but Wong and Rochen (2009) contend
that there are secondary benefits from writing, such as a decrease in psychological
distress. Writing also facilitates healing and coping and helps clients set goals and
increase self-awareness (Cook, 2011; Degges-White & Davis, 2011). In addition,
writing can serve as a starting point for discussion during counseling sessions and
is especially effective with shy or introverted young clients (Davis & Voirin, 2016).
Writing is very beneficial with clients from diverse backgrounds and has been used
for many different types of problems, such as those who have experienced trauma
(Degges-White & Davis, 2011) or sexual abuse (Kress, Hoffman, & Thomas, 2008).
Writing can also facilitate recovery for young clients dealing with anxiety or depression (Vernon, 2009). Suffice it to say that therapeutic writing is a very viable approach
that can be used to address a multitude of problems.
TYPES OF THERAPEUTIC WRITING
As previously noted, some mental health practitioners may be reluctant to use
writing with their clients because they associate it with creative writing. This may
be the case if the client is writing poetry or stories, but there are many different
types of therapeutic writing that do not require creativity and that are very helpful,
especially with adolescents.
Many clients benefit from journaling, which helps them reflect on their personal
experiences to gain insight. It is especially effective with adolescents because it is
non-threatening and cathartic and helps them clarify values (Vernon & Barry,
2013). It is also a good approach to use with non-verbal clients. Journaling can be
structured or unstructured, but with children and some adolescents, a structured
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approach may be more helpful because they may not know where to begin if they are
just asked to journal about their thoughts, feelings, and experiences. In structured
journaling, clients may be asked to write about a high or low point of the week,
things they were proud of or challenged by, and so forth. Clients can also journal
about their hopes, fears, and dilemmas.
There are also many benefits to writing letters. When I was a teenager, my mother
and I wrote letters to each other when we had disagreements. For me, this was very
helpful, and I am a firm believer in this form of therapeutic writing because it can
be a powerful form of writing that empowers clients to tell their story (Desmond
et al., 2015). Letter writing can be used in several ways. For example, young clients
can share thoughts and feelings with another person to improve communication or
resolve conflicts. These letters may or may not actually be sent, but regardless, they
promote catharsis and perspective taking and often result in problem resolution.
Another form of letter writing is to write to something more abstract, such as an
illness, a loss, a feeling such as depression, or a transition. When my spouse and
I sold the house we had lived in for over 20 years, I wrote a letter to it, expressing
how I felt about leaving and what wonderful memories I would always have about
living there. This was very cathartic and helpful for me.
Reciprocal writing is “an innovative strategy that uses a back-and-forth writing
sequence to solve client problems” (Davis & Viorin, 2016, p. 69). In essence, the
counselor and client write back and forth to each other, using the traditional paper
and pencil approach, or utilizing technology, such as using two computers or instant
messaging. This alternative form of communication, which focuses on collaboration
and finding solutions, helps clients express themselves.
Poetry is both a form of literature and therapeutic writing. It has been used throughout the ages to promote healing and growth. Writing poetry can be very cathartic and
improves interpersonal and communication skills, as well as promotes change and
coping (Vernon & Barry, 2013). For young clients who are uncertain about writing
poetry, the counselor can ask specific questions about an event or an experience and
write the words as the client expresses them and then put them into verse form. Poetry
can be used with clients dealing with many different types of problems, including
transitions, loss, troubling emotions, or relationship problems. Another form of
poetry, limericks, can be a good way to help younger clients discover their own problem-solving and coping strategies. I made up the following limerick for a girl who
felt sad: There once was a girl named Sue, who was tired of feeling so blue. She wanted
to have fun, so she played in the sun, and after awhile she felt like new!
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Structured writing is an excellent way of helping children and adolescents express
themselves. Open-ended sentences, questionnaires, or activity sheets all promote
insight and facilitate expression. I used open-ended sentences with a non-verbal
adolescent who had major anger problems but wasn’t able to articulate what triggered
his anger or how he experienced it. I also found it helpful to use “Write Through It,”
an activity sheet to help a middle schooler gain more perspective about friendship
conflicts. The client wrote about a recent conflict by responding to questions on
the activity sheet: what happened, who was involved, how did she feel at the time,
what might her friend’s perspective about the conflict be, what she would like to
see happen, and what could she do to solve the problem? (Vernon & Barry, 2013).
WAYS TO USE THERAPEUTIC WRITING
As with play and games, various forms of therapeutic writing can be used for building
rapport, as well as for problem assessment and intervention.
Rapport-Building
If I knew ahead of time that a child or adolescent was very reluctant to come to
counseling, I would often write him or her a short letter, explaining a bit about
who I was, how I helped kids their age, and what counseling sessions were like. I
usually suggested that they bring pictures or something meaningful to them so that
we could become better acquainted. I also used structured writing, such as “Write
About Me,” an activity sheet that requires clients to write about aspects of themselves: what they do well, what they are proud about, three words that they would
use to describe themselves, and so forth. I participated in this activity as well, and
the client and I shared what we had written, which helped develop the therapeutic
alliance (Vernon & Barry, 2013).
Problem Assessment
Open-ended sentences and checklists are excellent tools to use in problem assessment.
I generally create my own so that I can tailor the questions to gain more information
about the presenting problem. For example, when I was working with an adolescent
who was skipping school but wouldn’t talk about it, I developed questions such as
“When I go to school I feel …”; “The reason I don’t like going to school is …”; “Something that would make it easier to attend school would be … “; “If I could change
something about my school experience it would be … .” Based on his answers I was
able to develop specific interventions to help address the problem.
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Checklists and questionnaires can be used in a similar manner. It is best to keep
these forms of assessment relatively short so that the client doesn’t become overwhelmed or lose interest. Based on experience, just a few questions can yield a lot
of information.
Intervention
Although therapeutic writing can effectively address so many different types of
problems, it is not advisable to use it if it is not a “good match” for the client. On
the other hand, because writing serves as a “visual record” of progress, I usually
try to find some form of writing that is appropriate. For example, one of my clients
started writing poetry when she first became depressed as a way of catharsis, but as
she and I read her poems after several weeks in counseling, we were both able to see
growth and healing. Several examples of therapeutic writing are described as follows.
•
Word Cluster—This intervention, which I have found to be very effective, is
illustrated in Figure 3.2. The counselor or client identifies a key word such as
anger, anxiety, or whatever emotion or issue is problematic and writes it in
the top circle. The client then writes other words that relate to the key word:
people, places, emotions, situations, and so forth in the connecting circles.
Having used this many times, I can guarantee that it stimulates a lot of discussion that can lead to problem clarification and resolution (Adams, 1998,
as cited in Gladding, 2016, p. 130).
FIGURE 3.2 Word cluster.
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•
Lifeline—This intervention is more appropriate for adolescents who have more
life experiences upon which to reflect. To implement, the counselor asks the
client to draw a long line across a sheet or paper, and at one end, place a symbol
of a baby to represent birth, and at the other end, a symbol to indicate something
about themselves currently. They divide their lifeline into two-year periods, and
for each period, they write words or sentences above the line to describe positive
events and words or sentences below the line to describe negative events. This
intervention helps adolescents reflect on their life experiences, work through
negative experiences, and gain perspective on their life up to that point.
•
Write Around—This intervention is good to use in a small group. For example,
when I was conducting an anger management group, I gave one group member
a sheet of paper with the sentence starter (“A good way to manage my anger is
…”) and explained that each person in the group would respond to this starter,
but the paper would be folded over after each response so no one would know
what the participants before them had written. They each had a minute to write
a response. When every group member had responded, I handed the paper
to one member and asked her to read aloud one of the responses (not the one
she had written), and then pass it to the next person to read the next response
aloud, and so forth. I followed this sharing with more discussion about anger
management strategies. This process can be used with a variety of topics.
MUSIC
Music is a very powerful and persuasive medium that has been used therapeutically
over time (Armstrong, 2016; Avent, 2016). According to Armstrong (2016) “music can
convey the complexity of our feelings better than words can” (p. 61). There is strong
research support for using music within the context of counseling and therapy (Stephensen & Baker, 2015) and increasing evidence that it stimulates brain activity and
has mood-altering effects (Schweitzer, 2014). Recent neuroimaging studies have demonstrated that music influences brain structures connected with emotion and associative
learning and stimulates activity in the pleasure centers of the brain (Armstrong, 2016).
Music promotes healing by helping clients reframe problems, thereby improving
physical changes in heart rate and blood pressure (Eckhardt & Dinsmoore, 2012).
Because it is universal in nature, it appeals to people from many different cultures.
Music is an alternative form of communication that is especially effective with clients who have difficulty expressing themselves verbally. As Gladding (2016) notes,
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“[M]usic can elicit a wide range of mental, emotional, physical, and spiritual responses”
(p. 24). It is important to distinguish between music therapy, in which music is specifically prescribed by specially trained therapists, and using music as an adjunct to
counseling. Practitioners who use music in counseling should be familiar with different
musical modalities and which would be most effective with particular clients.
ADVANTAGES OF USING MUSIC
There are many advantages to using music, not only in individual counseling, but
also in classrooms and small groups. Experts agree that it can decrease emotional
distress (Cook & Silverman, 2013), promote positive mental health and facilitate the
expression of emotions (Duffey, 2007), change unproductive behavior (Minor, Moody,
Tadlock-Marlo, Pender, & Person, 2013), help clients work through painful memories
(Duffey, 2007), and promote self-confidence (Gladding, 2016). Music can increase listening skills (Kane, 2012) and stimulate emotions that promote understanding (Wilson
& Ziomek-Daigle, 2013). Because music is so universally appealing, it is a very viable
approach to use with young clients for a wide variety of problems, including grief and
loss (Armstrong, 2016), depression (Wilson & Ziomek-Daigle), chronic illness (Gladding, 2016), trauma (Armstrong, 2016), parental divorce (DeLucia-Waack & Gellman,
2007), behavioral disturbance (Kane, 2012), and typical developmental problems.
TYPES OF MUSIC
Music can take on many forms, including listening, improvising, chanting, drumming, rhythm activities, composing, and performing. Musical interventions can
impact young clients in multiple ways, and they are even more effective when
combined with other creative arts techniques, such as drama, poetry, storytelling
(Gladding, 2016), photography, and play (Vernon & Barry, 2013). Although music is
very appealing to school-age clients, some may be reluctant to compose or perform
their own music, so it is important to know which type of musical modality would
be most appropriate for a particular client.
Depending on the client and the problem, the counselor may introduce a song
related to the client’s problem, and, after listening to the music, discussion can focus
on the client’s reaction to the song and how it did or did not apply to him or her.
Another alternative is to ask the client to select a song or a series of songs to depict
what he or she is thinking or feeling. Clients who play musical instruments can share
how they are dealing with a particular issue by composing or selecting a song and
playing it on their instrument.
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WAYS TO USE MUSIC
Rapport-Building
Music can be very effective in establishing rapport, especially with adolescents. I
often had music that would be relevant to teens playing softly in my office when
they presented in counseling for the first time. I found that it seemed to relax them
and was a way to initiate conversation by asking if they liked listening to music,
what types of music they preferred, and so forth. I also used short self-composed
songs to help young clients feel more at ease. For example, during a session with a
child who had behavior problems, I introduced the session by singing this song to
eight-year-old Katia: Are you behaving, are you behaving? Yes you can, yes you can.
Follow all the rules, use your management tools, you are behaving, you are behaving.
(Vernon, original—to the tune of “Are You Sleeping?”). Katia laughed as she listened
to me sing and when I was finished, we talked about the management “tools” she
was using and how they were working.
Problem Assessment
Music can be very useful in problem assessment. For example, if your client is creative, suggest that he or she write an original piece of music to express his or her
concerns (Jayne & Purswell, 2017). You can also learn a lot by asking adolescents to
print lyrics of favorite songs from the Internet and underline words that describe
them and their feelings. Encouraging young children to “make mood music” using
pots and pans, rattles, harmonicas, and so forth can also be a good assessment tool.
Intervention
As previously noted, musical interventions are often used in conjunction with
other creative arts approaches. I was working with a 10-year-old whose parents
were getting a divorce. We first listened to Dan Conley’s song “Divorce” (1994) and
after discussing how she related to the song, I gave her a copy of Getting through
My Parent’s Divorce: A Workbook for Children Coping with Divorce, Parental Alienation, and Loyalty Conflicts (Baker & Andre, 2015), which contains activities to
help children deal with their feelings and learn new coping strategies. In a small
group on anxiety, I used another Conley (1994) song, “I Worry,” playing this at the
beginning of the session and following up with the hopscotch game “Adios Anxiety” (Vernon, 2002). I also addressed co-dependency in relationships by having
an adolescent listen to the well-known song by Mariah Carey, “How Can I Live if
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Living is Without You.” After discussing the client’s reaction to the song, I followed
up with bibliotherapy, asking her to read several articles on co-dependency. Three
musical interventions are subsequently described. Refer to Vernon and Barry (2013)
for additional interventions.
•
Music Mobile—For this intervention, you need a coat hanger, six pieces of
string cut in various lengths, and six tag board circles with a hole at the top.
Before slipping the string through the hole of each circle and tying it to the
coat hanger, have the client either compose a short song or find lyrics to songs
on the Internet that identify ways of coping with a problem he or she is dealing with, write these lyrics on the circles, and attach them to the coat hanger.
Children can refer to their mobile for problem-resolution strategies.
•
Line Spacers—This intervention was developed by Gladding (1995) and involves
asking clients to find examples of songs that inspire hope or describe ways
to deal with difficult circumstances. They write out the lyrics and make a list
of words or phrases that are encouraging and helpful, referring to these lists
when they need support.
•
Take a Sad Song and Make It Better—I developed this intervention for
depressed adolescents who tend to listen to sad songs, which depresses them
even further. I suggested that they take lyrics to songs they listen to when they
are depressed and rewrite more uplifting and hopeful lyrics. This has proven to
be an effective way of helping them deal with their depression (Vernon, 2002).
Now it is time for you to try out one of the creative arts interventions you have
read about thus far. Refer to the “Now Try This!” sidebar.
NOW TRY THIS!
Now that you have read about three different creative arts approaches, pick
the one that you think has the most potential for helping clients you work
with (or anticipate working with in the future). Select an actual problem of
one of your clients (or a hypothetical problem if you aren’t currently working
with clients). Re-read, if necessary, the examples that were provided and
adapt one of them or create an entirely new one for your client or future
client, based on the problem you selected. If you are actually working with
this client, try out your new intervention to see how it works!
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VISUAL ARTS
The visual arts are very applicable for a wide range of problems experienced during
childhood and adolescence, offering an alternative form of expression for clients
who may not be able to express their concerns verbally. Drawing, painting, coloring, photography, sculpture, and various other forms of art media can facilitate the
counseling process. Malchiodi (2012) notes that it is “now widely acknowledged
that art expression is a way to visually communicate thoughts and feelings that
are too painful to put into words” (p. ix). According to Gladding (2016), the visual
arts are defined as “those processes within the realm of art that focus on visually
representing reality symbolically or otherwise” (p. 92). They are usually perceived as
non-threatening and can be readily combined with other creative arts interventions,
thus increasing their versatility.
Nichols (2013) contends that seeing something visually is often more impactful
than expressing it verbally. Not only are the visual arts cathartic, but they facilitate
problem-solving and skill development, help clients perceive themselves more clearly,
and are very applicable with diverse populations because they transcend cultural
boundaries. It is important to distinguish between art therapy and using the visual
arts as an adjunct in counseling. Art therapy, which is not the focus of this chapter,
is a specialized profession with training and credentialing and entails using art in
a therapeutic way to facilitate self-expression (Vick, 2003).
ADVANTAGES OF THE VISUAL ARTS
As with other creative arts approaches, there are numerous advantages of the visual
arts. First, they are experiential, hands-on activities, which are engaging for the client.
In addition to providing an emotional outlet for clients, visual arts techniques help
them articulate thoughts and feelings that they cannot express verbally. According
to Nichols (2013), using visual arts strategies helps clients picture themselves or
their situation more concretely. Also, “the visual arts have been instrumental in
fostering the growth of culture and the mental health of people around the world”
(Gladding, 2016, p. 93). Another appealing feature of the visual arts is that they
produce a tangible product that can help monitor progress in counseling (Vernon
& Clemente, 2005). They also stimulate the release of feelings and help clients recall
details (Malchoidi, 2005). In schools, the visual arts encourage school engagement,
collaboration and belonging, innovative thinking, and problem-solving. They also
improve social skills, attention, empathic understanding, and cognition (Ziff, Pierce,
Johanson, & King, 2012).
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TYPES OF VISUAL ARTS
The visual arts are very versatile because there are so many different approaches
that can promote growth and healing. Since they can readily be paired with other
creative arts approaches, they are even more effective.
Photography, or phototherapy, is one of my favorite visual arts approaches
that can be used in a variety of ways to improve understanding and perception.
Gladding (2016) distinguishes between active photography, in which clients take
pictures of things that are significant to them, or passive photography, in which
clients find photos that have previously been taken that represent something about
them. These photos can be displayed in a poster or a scrapbook and the client
and counselor can discuss them. As clients reflect on the photos, they are able to
feel and “see” situations and issues they are dealing with (Loewenthal, 2013) and
uncover themes that they may want to alter. Stevens and Spears (2009) contend
that taking photos can increase clients’ sense of mastery, thus improving their
self-esteem and functionality.
I used photos with a young client whose family was moving to a different state,
which was upsetting because he would live very far away from his friends. I suggested that he take a photo of each friend and collect any photos of these friends
that had already been taken. I combined this with expressive writing, explaining
that he could paste the pictures of each friend on separate pages and write about
his memories with each of them.
Art media can be used to help clients express feelings about a particular issue
or event, using clay, crayons, material scraps, pipe cleaners, paint, and so forth
to “show” what they are experiencing. It can also be used in a more directed
manner to facilitate a process, such as drawing a picture of their family doing
something, painting a picture of something they are afraid of, or using clay or play
dough to depict conflicts with peers. Older children and adolescents can use art
media to represent something they need in their life or design a T-shirt, banner,
or poster with a motto that characterizes their strengths and talents to improve
self-esteem.
Art media can also be used very effectively in a small group to build group
cohesion. For example, when I was a school counselor I asked a group of third
graders to make a collage to illustrate what characterized a good friend. I also used
photography with fifth graders who were in a study skills group, asking them to
take pictures of practices that they thought represented good study skills and make
them into a poster.
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WAYS OF USING THE VISUAL ARTS
Rapport-Building
The arts can be used to build rapport, especially with non-verbal clients. Asking
clients to draw a picture about themselves or their problem or initiating contact
during the first session by putting several forms of media on the table for younger
clients to “play with” often puts them more at ease. With adolescents, I sometimes
ask them to bring their yearbook and show me pictures of their friends, activities
they participate in, and so forth.
Problem Assessment
We’re all familiar with the phrase “a picture is worth a thousand words.” Especially
when working with children and adolescents who aren’t as verbal or adept at expressing themselves, the visual arts play a critical role in problem assessment. However,
we must be careful not to over-interpret what we see. This was reinforced for me
when one of my counseling interns showed me a picture that 10-year-old Ryan had
drawn that depicted a great deal of violence. Ryan was in a divorce group that she
and I were co-leading and she assumed that his drawing represented conflict at home
since the family was going through a difficult time. When I asked Ryan about the
picture, he said that that it was about the movie he had watched the previous night
with the baby sitter! With this caution in mind, it can be very helpful to ask children
to draw or paint pictures or use play dough, clay, or other media to convey what they
are experiencing and then discuss it with them to learn more about the problem.
Intervention
Clients with many different types of presenting problems can benefit from the visual
arts, but it may not be the best “fit” for some clients who may think they have to
be precise in what they create, which of course is not the case. I found it helpful to
combine expressive writing with the visual arts by having clients make books about
an issue they were dealing with, writing the dialogue, and illustrating with pictures
or photos. I used photography with a teenager who was very angry at her parents for
forcing her to go to summer camp. She was certain that she wouldn’t make friends or
like any of the activities, and she knew she would have a terrible time. I encouraged
her to take photos so that if it really was as bad as she predicted she would have a
visual representation to show her parents if they wanted her to go again. When she
returned after camp and shared her pictures with me I acted quite puzzled, saying
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such things as, “Is this really you in this photo? I thought you said you wouldn’t
make friends, but if this is you, it looks like you did make friends?” “I thought you
said you would have a terrible time, but it looks to me like you are laughing and
having fun. So, how was camp?” This intervention really helped Raquel challenge
her doom-and-gloom thinking and erroneous assumptions. The following original
visual arts interventions have proven to be beneficial with young clients.
•
Competency Collage—This is a good intervention for children and adolescents
who are prone to self-downing in that it provides an opportunity for them
to look at their strengths as opposed to focusing on their weaknesses. I used
this with a young adolescent who was very self-critical, asking her to draw
pictures, take photos, or find words or pictures in magazines that represented
her strengths. After she had collected the visual images, she glued them on a
tag board in the form of a collage and put it on her bulletin board to remind
herself that she had lots of strengths (Vernon & Barry, 2013).
•
Make a Mask—This intervention can be used for a variety of problems. I
used it with 4- and 5-year olds who were afraid that monsters were hiding in
the bedroom. After discussing more about where the monsters were hiding,
I explained that we could probably frighten the monsters away by making a
very scary mask and putting it somewhere in the room so the monster would
see it, get scared, and disappear. This has always proven to be an empowering
way of helping them deal with this fear. I also used it with adolescents who
“hide” behind a mask of cheerfulness when they are really hurting inside.
After discussing this concept of hiding behind a mask, I invite them to make
a mask and on the outside, write what they are masking on the inside. This is
a good springboard for further exploration and expression of feelings.
•
Build a Statue—The purpose of this intervention is to develop skills in working effectively with others and is best suited for adolescents in a small group
or classroom setting (if used in a classroom, subdivide the class into smaller
groups of four to six persons). Provide each group with scissors, masking tape,
magazines, construction paper, yarn and ribbon, material scraps, and glitter.
Explain that they will have 25 minutes to create a unique statue that is at least
10 inches tall and, when displayed, is self-supporting. They can only speak for
the first 10 minutes during the planning stage. Appoint an observer for each
group who will give feedback on how group members worked together, the
roles each person assumed, how they communicated, and so forth.
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LITERATURE
Bibliotherapy, sometimes referred to as bibliocounseling, is the term used to describe
the therapeutic use of literature to facilitate growth and healing (Gladding, 2016), as
well as increase understanding of self and others (McCreight, 2018). It is an interactive process that helps clients of all ages address a wide array of problems (Parsons
& Nord, 2013) and is especially effective with clients who are visual, as opposed to
auditory, learners (Vernon, 2017). In addition to literature in print, cinematherapy is
a powerful medium in which movies, TV episodes, videos, or movie clips are used
to facilitate catharsis and identification of coping strategies, just as in bibliotherapy
(Shallcross, 2011). Cinematherapy is considered an extension of bibliotherapy that
improves learning and facilitates growth, and it is especially appropriate with clients
who don’t like to read (Dantzler, 2015). “The human brain is wired to connect with
and be activated by cinema” (Robertson, 2016, p. 51), and according to Shallcross
(2011), is effective because clients are “not processing it in their head; they’re processing it in their heart” (p. 37).
Bibliotherapy and cinematherapy help clients develop greater self-awareness,
learn new ways of behaving, and find alternative solutions to problems (Henderson
& Thompson, 2016). These approaches help clients realize that others have similar
problems, which reassures them that they aren’t the only ones who are struggling.
They also develop insight and understanding as they learn how others have dealt
with the same sort of issues. Bibliotherapy, as well as cinematherapy, is a directed
process and is not intended to be confused with reading or watching something for
pleasure, even though most clients enjoy both approaches (Gladding, 2016). It is very
important to select materials that are developmentally and culturally appropriate
and match the client’s reading and comprehension level. The selections should relate
to the presenting problem and reflect the client’s age, gender, culture, and family
values. They should offer hope but not have magical “happy ever after” endings, and
the characters should be believable (Dollarhide, 2003).
ADVANTAGES OF LITERATURE
Bibliotherapy and cinematherapy are versatile approaches because so many different
creative strategies can be used in conjunction with them. Not only do they provide
emotional release, but they also help clients explore relevant thoughts and behaviors.
Furthermore, they help clients gain control over their lives (Vernon, 2017) and they
are applicable for a wide range of problems, including mastering fears (Gladding,
2016), dealing with loss and grief (Slyter, 2012), facilitating understanding and
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communication (Ballard, 2012), dealing with addiction (Shallcross, 2011), navigating
the challenges of puberty (Bartlett, 2003), dealing with transitions (Thomas, 2013),
and helping clients deal with parental divorce (Pehrsson, Allen, Folger, McMillen,
& Lowe, 2007). Bibliotherapy and cinematherapy can be used effectively individually as well as in small groups or classroom settings. Not only can these approaches
be used remedially to address current problems, but they also are very powerful
in prevention where the focus is on personal growth and developing skills to help
children and adolescents deal with the challenges of growing up (Vernon, 2017).
TYPES OF LITERATURE
Fiction and non-fiction, poetry, fairy tales, self-help books, autobiographies, and
movies are all viable approaches to use with young clients. In addition, creating
comics with clients is very engaging and effective (McCreight, 2018). All these methods are designed to promote insight and perspective-taking. Literature can also be
combined with other creative arts interventions, as the following illustrates.
Eleven-year-old Aamiina had anger management issues but wasn’t motivated
to work on them. During our second session, I gave her an anger survey from Hot
Stuff to Help Kids Chill Out: The Anger Management Book (Wilde, 1997), and since
I knew she didn’t really like to read, I had recorded this short book that contained
very practical information about anger and included several activities. Together, we
listened to the first 15 pages, which only took a few minutes, and then discussed the
top five ways anger messes with your life. She completed the short activity and we
discussed her responses. I then gave her a glass of water, an Alka-Seltzer tablet, and
some red food coloring and asked her to add red drops to the water to show me how
angry she usually gets when she and her parents or friends have conflicts. Then I told
her to put the Alka-Seltzer tablet into the water, and we discussed what happened
when the water fizzed and bubbled over the top, drawing similarities between this
and her anger. In the following sessions, she continued to listen to short segments
of the book and I implemented other creative arts interventions to help her learn
how to control her anger.
WAYS OF USING LITERATURE
Rapport-Building
If young clients like to read, literature can be a good way to develop rapport. I recall
working with an adolescent whose parents, in her opinion, were too controlling.
I shared a letter that I had written to my parents when I was 17, expressing similar
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sentiments (Vernon, 1998). After reading it, she immediately said that the letter
expressed exactly how she felt, so I then told her that I had written the letter years
ago when I was her age. I think this helped my client realize that I understood her
issues, which in turn strengthened the therapeutic bond.
Problem Assessment
I recall working with 16-year-old Marta who claimed that she was very depressed,
but she masked these feelings well and didn’t display the usual signs of depression.
I had Marta read several poems written by another of my depressed clients who had
given me permission to share them. After reading these poems, Marta said that she
identified with the thoughts and feelings expressed in the poems, which gave me a
better sense of the problem. I also often read short books to younger children to get
a better sense of a presenting problem. Being Bella: Discovering How to Be Proud
of Your Best (Zugo, 2008) helped me learn more about a young client’s issues with
perfectionism.
Intervention
In using bibliotherapy or cinematherapy, it is important that it be an interactive process where the client reads (or watches) something that the counselor has selected and
then they discuss it. Years ago, I developed a process that works very well. I first ask
several content questions to get a sense of how well clients understand the concepts/
content and then I ask personalization questions that help them apply the concepts
to their own situation. According to Kelsch and Emry (as cited in Gladding, 2016),
there are four stages to the bibliotherapy process: identification with the characters,
situation, and setting; catharsis (emotional connection); insight (applying concepts
to their lives); and universality (clients are more empathic and move beyond their
immediate situations).
•
Read All About It—Adolescence can be a confusing and conflicting time,
and it is not at all uncommon for adolescents to think they are crazy because
they experience so many up-and-down emotions during puberty. I developed a short handout that I shared with my adolescent clients, describing the
normality of the yo-yo emotions and why they are experiencing them. This
intervention was very informative and reassuring to many clients. Both fiction
or non-fiction can be helpful.
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•
Biographies—I often use biographies with clients who have unrealistic goals or
think they shouldn’t have to work hard to achieve their goals. Twelve-year-old
Antonio wanted to be a great basketball star, but he was very erratic about going
to practice. I had him read Salt in His Shoes, a story of Michael Jordan’s road to
success (Jordan & Jordan, 2003). After he read it, we discussed how Michael actually had to work hard in order to succeed, and we began developing realistic steps
to help Antonio reach his goals. Biographies can also be helpful for young clients
who suffer from chronic illness or a disability and can benefit from the messages
of courage and perseverance conveyed in carefully selected pieces of literature.
•
Show Me What You Read—After reading fiction, non-fiction, or poetry prescribed to address a specific problem, ask clients to show you what they read
by making a poster, a collage, or a painting. Some may prefer to illustrate the
content by creating a comic strip.
DRAMA
There are multiple ways to integrate drama into counseling, and it is especially
effective with adolescents who by nature are rather dramatic (Slyter, 2012). Drama
has been used throughout the ages to help clients gain control of their lives as they
develop greater awareness about their life roles. According to Guli, Semrud-Clikeman, Lerner, and Britton (2013), drama interventions are interactive, and through
participation, clients learn more about communication and cooperation, emotions,
and interpersonal relationships. They may also gain insights into themselves and
work through conflicting issues.
For the last several years, my grandchildren and I have been putting on plays,
primarily created by Elia, who is now 11. During the first play, based on a mermaid theme, we had to take a time out because I hadn’t remembered my lines! We
practiced more for the next play because Elia told her brother Niko that “it was too
embarrassing last time when Nanna forgot her lines!” This year, she explained to
her parents that since she and Niko are now more mature, our plays will be a lot
better (and they are)! It is very interesting to see how their personalities emerge as
they play different roles and listen to what transpires from their improvisations.
ADVANTAGES OF DRAMA
Drama can be very intriguing and engaging and is especially effective because it is a
safe and powerful way to express feelings (Jencius, 2011). It also increases creativity
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and spontaneity, which I observed with my 9-year-old grandson who was much
more spontaneous and confident in his “role” as a teenager in our last play. Another
advantage of using drama is that it helps clients “try on” various roles, rehearse new
skills, practice different responses to situations, and change dysfunctional behaviors
(Lane & Rollnick, 2007). In a group setting, drama promotes social interaction and
cohesiveness (Sheesley, Pfeffer, & Barish, 2016). Drama also improves concentration
and problem-solving (Vernon, 2017), which I observed first hand when my grandchildren were a bit “stuck” when they were trying to figure out the theme for last
summer’s play. It was intriguing to listen to them assertively express their opinions,
argue, and ultimately blend their ideas together to form a coherent plot.
TYPES OF DRAMA
Most counselors use role play and reverse role play to help children and adolescents
improve perspective-taking and problem solving, develop empathy, and heighten
awareness of their choices. Another form of drama that is appropriate for young
children is using puppets to express feelings and resolve problems. Sculpting can
also be used in a group setting to help members work through conflict and become
more cohesive. Performing plays and putting on skits also provides opportunities
for young clients to work together to create and perform, which can have a positive
impact on self-esteem. Gladding (2016) describes how watching movies, where “the
power and the potential of drama come to the forefront” (p. 161), helps clients become
aware of their own emotions and what they might like to change in their lives.
WAYS OF USING DRAMA
Rapport-Building
Inviting younger children to act out something with puppets is a good rapport-building activity because this non-threatening approach helps them relax and engages
them in the counseling process. Having a basket of dress-up clothes also appeals to
elementary-age children and they are usually eager to use the costumes to act out
a problem they would like to solve.
Problem Assessment
Role play and reverse role play are excellent assessment techniques. I was counseling a
10-year-old from a very dysfunctional family. Andre was not willing to talk about his
experiences, so I invited him to play the role of his mother and I would be him. I learned
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a great deal about the family dynamics by observing his portrayal of his mother and
how she treated him. Drama is also effective in assessing how children and adolescents
work together in a group. As a school counselor, one of my favorite interventions was to
give a small group of 4 to 6 children a paper bag containing eight to 10 miscellaneous
objects to incorporate into a skit. This intervention revealed how well they could communicate and collaborate, as well as the roles they assumed in the group.
Intervention
Drama can easily be combined with other creative arts activities. Clients can write
a story and then act it out, and adolescents enjoy using music in conjunction with
a skit or play to convey emotions, conflict, or suspense (Vernon & Barry, 2013).
Another excellent drama intervention is the empty chair dialogue, in which the
client first sits in one chair and “talks” to someone else, and then switches chairs
(Okun, 2007). The Adlerian “Act as If” strategy, in which clients identify what they
would like to change in their lives and how their lives would be different if they
made these changes, is also effective for many clients. They are then encouraged to
“act as if” they were able to make the change (Vernon & Barry, 2013).
•
Please Perform—This intervention works best with younger clients and involves
having them perform a puppet play based on a current problem. I used this
intervention with 5-year-old Axel who could not articulate his anxiety about
going to school until he put on a puppet play with his animal friends.
•
Act Out the Solution—This intervention is good for young teens because in a
small group setting it engages them in acting out solutions to decision-making
dilemmas typically experienced during adolescence. Topics can include peer
pressure, cheating, family conflict, and so forth.
•
Which Hat Will You Wear?—This intervention is particularly applicable for
young adolescents in a small group or classroom setting. At this age, they
are trying out various roles and trying to decide if they will be risk-takers,
followers, leaders, and so forth, and this intervention allows them to “try on”
these roles and consider the advantages and disadvantages of each. Working
in pairs, one student puts on a hat with a label, such as risk-taker, and “speaks”
to his or her partner regarding the positive aspects of taking on this role while
the partner cites negative consequences. An observer in each group writes
down both the positive and negative aspects, which will be discussed during
the debriefing stage with other group members.
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TAKE-AWAYS FROM CHAPTER 3
As I conclude this chapter, I would like to refer to the vignette at the beginning of the
chapter and share what I learned from working with Manuel, as well as a technique
I used that I thought was effective. The most important thing that was reinforced
for me was that talk therapy doesn’t work well with young children whose attention
spans are limited! I realized almost immediately that I needed to do something to get
him moving, and I thought the jogging exercise was effective. Another intervention
I used in a subsequent session was to put 10 paper plates on the floor, spaced so that
he could easily jump from one to the other. I used examples based on behaviors
he displayed in the classroom and read them aloud, one by one. Before he could
jump to the next plate, Manuel had to share something that he could try that could
reduce the disruptive behavior in the example I had just read. He responded well to
this movement activity and was able to generate several good ideas that I put into
a behavioral contract.
After reading this chapter, you should now have more knowledge about these
key points:
•
The rationale for using the creative arts with children and adolescents
•
Numerous creative interventions for using play and games, music, therapeutic
writing, the visual arts, literature, and drama
•
How to combine one or more creative arts approaches
•
The versatility of these approaches and how the same technique can easily be
adapted for many different types of problems
•
The importance of taking cultural and developmental factors into consideration
when designing interventions
•
How to apply the various interventions, as illustrated through case examples
Think about which of the creative arts approaches might be a best fit for you by
reflecting on the questions in the “Personal Reflection” sidebar on this page.
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PERSONAL REFLECTION
After reading this chapter, which of the six creative arts approaches do you
think you would be most comfortable using, and why? Which ones would
be the least comfortable for you, and why? Do you think you will try some
of the interventions that you might be uncomfortable with but that could be
effective with a particular client? Do you see any advantages or disadvantages in trying things you might not be comfortable with, at least initially?
HELPFUL WEBSITES
www.arttherapy.com
www.playtherapy.org
www.creativecounselor.org
www.nadt.org
PRACTICAL RESOURCES
Hesley, J. W., & Hesley, J. G. (2001). Rent two films and let’s talk in the
morning: Using popular movies in psychotherapy (2nd ed.). Hoboken, NJ:
Wiley.
Slivinske, J., & Slivinske, L. (2011). Storytelling and other activities for children in therapy. Hoboken, NJ: Wiley.
Journal of Creativity in Mental Health (American Counseling Association).
Vernon, A., & Barry, K. L. (2013). Counseling outside the lines: Creative arts
interventions for children and adolescents—Individual, small group, and
classroom applications. Champaign, IL: Research Press.
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CHAPTER 4
Play Therapy
Rebecca Dickinson and Terry Kottman
LEARNING OBJECTIVES
1.
To explore the basic play therapy skills and how they are used in a play therapy
session
2.
To describe the logistics of setting up a play therapy space and how to select
toys and play materials
3.
To describe several play therapy theoretical orientations
M
alachi, a 7-year old African-American male, entered the child welfare system
as a toddler, due to neglect. He experienced multiple foster placements,
including two failed adoptions, before being placed at age 6 as a foster
child with Bob and Diane. After living with the family for less than six months, Bob
and Diane scheduled an appointment with me (Rebecca) due to concerns about his
impulsivity and a low frustration tolerance, which frequently resulted in aggressive
behavior or destruction of property. Additionally, Malachi wet the bed almost nightly
and hid his soiled clothing. He also demonstrated hoarding behaviors, “collecting”
insignificant items, such as scraps of paper and pens. His teacher described him as
extremely disorganized and reported that his desk was constantly surrounded by
paper shreds and bits of objects torn from school materials or from his shoes. She
also noted that he frequently chewed on his clothing. When asked to do schoolwork,
Malachi would have a “meltdown,” collapse on the floor, and could become aggressive
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if the teacher tried to pick him up. The teacher believed he just didn’t want to do the
work and was intentionally avoiding it.
Malachi was extremely cautious during his initial session in the playroom. He
examined the toys but did not engage with anything in the playroom. He paced in
slow circles around the playroom, occasionally reaching out to run a finger over
something. He generally ignored my tracking and reflection of his actions and
statements, and although he repeatedly questioned whether his foster mother was
waiting for him in the waiting room, he did not seem reassured when I told him that
she was there. Several times he questioned if he had to come to therapy because he
was “bad” and got “in trouble a lot.” Malachi gave me a run-down of his “naughty”
behaviors that he believed had caused the disrupted foster placements and adoptions.
His list of “transgressions” included not eating his supper, not cleaning his room,
not listening to his teacher, and arguing with foster siblings
I initially utilized non-directive activities with Malachi but quickly abandoned
this method after the third session because Malachi’s anxiety about being in the
playroom with unstructured play time did not ease. He continued to examine the
toys from a distance and question whether his foster mother was waiting for him.
In the fourth session, I began using directive activities with Malachi. He was very
willing to engage in activities that allowed him to invent things because he had a
particular interest in art and creative expression, as well as in building and engineering. He used a lot of glue, tape, and staples in each of his art projects, even when
there were not multiple pieces that needed to be held together. Malachi frequently
announced that whatever art project he was making was a gift for someone, typically
for a member of his foster family.
During the next 11 sessions, Malachi engaged in directive activities that utilized
his creative mind to solve problems. He began to respond when I reflected his positive
feelings, particularly when he showed pride about being able to do something for
himself. However, he ignored any reflection of negative feelings such as frustration.
Malachi eventually began exploring other toys in the playroom and engaging
in spontaneous, unstructured play. He was drawn to the puppets and often chose
a black puppy dog puppet. Although he didn’t identify the puppy as himself, his
puppy puppet frequently acted out by crashing into other puppets and knocking
them over. I tracked what the puppy was doing, noting how it seemed to leave a
mess behind. Malachi also stayed in the metaphor, providing more information
about the puppy, saying “It can’t help it; sometimes it doesn’t even know it is doing
it.” Over multiple sessions, Malachi offered more about the puppy, stating, “He
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can’t stay in one place. He’s always moving.” In another session, Malachi examined
the other available dog puppets, saying, “None of them look like him. These aren’t
his family. He needs to find his family.” Whenever I reflected difficult feelings
the puppy might be experiencing, such as being sad or lonely, Malachi abruptly
dropped the puppet and moved to another activity. Over time, Malachi began utilizing approximately half of each session in a directive activity, generally a small
task or problem I set out for him to solve, and then choosing nondirective play for
the remainder of the session.
Malachi had become very attached to the foster family’s numerous pets and farm
animals. While he struggled in interactions with people, he was very caring and
empathic towards animals. He began to create puppet shows representing the family’s farm animals, and a consistent theme was the inclusion of an animal who was
hurt or was getting into trouble. One of the foster parents’ adult children worked as
a veterinary technician, and she spent a great deal of time with Malachi, teaching
him about animals, how to handle them, and basic first aid techniques. Malachi
would pretend to be the veterinarian in his stories, caring for the hurt animal or
offering the animal advice if it was getting into trouble. At one point, I tried to tell
a metaphoric story using Malachi’s characters and themes, but he corrected my
technique in helping the hurt animal, announcing, “I know what it needs. I can
help it.” Through several weeks of similar play, Malachi became more comfortable
when I would reflect feelings that the animals were experiencing, even painful ones.
He even began to label the feelings himself as long as we could stay in the metaphor
and only refer to the animals who might be experiencing the emotions.
Over a number of sessions, as Malachi increased his problem-solving ability and
continued his puppet shows, he began to demonstrate less anxious behaviors both at
home at and school. He continued to display hoarding behaviors, but his bed wetting
had decreased from every night to a few nights a week. He was also less aggressive
toward peers and less destructive toward property.
I worked with Malachi’s foster parents to help curtail Malachi’s hoarding. Malachi
often described his “collections” as things he “might need someday.” In a family
session, his foster parents helped him create an “emergency preparedness kit,” listing
all the things he believed he would “need” if there was an emergency or if he had to
leave this home. Although the kit contained only a few items, it was very important
to Malachi and he referred to it often, reminding me of the session in which we came
up with the list, giving me a run-down of the kit’s contents, and explaining where
the kit was kept in his bedroom.
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Malachi and his foster family continued working with me on a weekly basis for over
a year. Although Malachi had made significant improvements, his anxiety would spike
around holidays and when there was a transition, such as the beginning of a new school
year. I worked with his school, and he was eventually tested for a learning disability
and qualified for additional educational support. His foster parents supported his
interests and involved him in organized youth activities, including sports and 4-H,
where he was able to showcase his talents and begin to develop relationships with
peers. Over time, his bed wetting abated. Because of their support and willingness
to meet him where he was, Malachi was able to develop a strong bond with both of
his foster parents. Despite “not looking like them,” he eventually expressed a desire
to be adopted by them, and when this occurred, he thrived in the family.
According to the Association for Play Therapy (APT) (2017), play therapy is “the
systematic use of a theoretical model to establish an interpersonal process wherein
trained play therapists use the therapeutic powers of play to help clients prevent
or resolve psychosocial difficulties and achieve optimal growth and development”
(para. 1). In play therapy, the counselor uses toys, art, games, dance and movement,
storytelling and metaphors, and other play media as the primary vehicle for communicating with young children. The rationale for play therapy is based on the belief
that young children (under the age of 12)
have relatively limited ability to verbalize their feelings and thoughts and to
use abstract verbal reasoning. Most of them lack the ability to come into a
counseling session, sit down, and use words to tell the therapist about their
problems…Children can come into sessions and use toys, art, stories, and
other playful tools to communicate with the therapist (Kottman, 2011, p. 3–4).
Because play is the natural language of young children, it is a very effective modality
for helping young clients solve problems and communicate with others. According
to Henderson and Thompson (2016), this makes play therapy an essential method for
counseling children younger than 12 years of age. Schaefer and Drewes (2014) delineated
20 therapeutic powers of play, including self-expression, access to the unconscious,
direct and indirect teaching, catharsis, abreaction, positive emotions, counterconditioning fears, stress inoculation, stress management, therapeutic relationship, attachment,
social competence, empathy, creative problem solving, resiliency, moral development,
accelerated psychological development, self-regulation, and self-esteem.
This chapter presents parameters for determining whether play therapy approaches
are appropriate in various situations, goals for play therapy, suggestions for setting
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up an ideal play therapy space, and choosing therapeutic toys and play materials.
We will also explore several theoretical approaches to play therapy, as well as multicultural applications and the importance of involving parents and caregivers in
the play therapy process.
APPROPRIATE CLIENTS FOR PLAY THERAPY
Although some play therapists work with adolescents and adults (Frey, 2015;
Gallo-Lopez & Schaefer, 2005; Gardner, 2015; Green, Drewes, & Kominski, 2013;
Schaefer, 2003), most play therapy is done with children between the ages of 3 and
12. When working with older elementary-age children, preadolescents, and young
teens, the counselor might ask whether they would be more comfortable sitting and
discussing their situation, playing with toys, or using art materials. The counselor
can extend the usual age range of play therapy by adding play materials that are
more appropriate for older children, such as craft supplies, carpentry tools, office
supplies and equipment, and more complex games or games that are designed for
specific therapeutic interventions (Ashby, Kottman, & DeGraaf, 2008; Gallo-Lopez
& Schaefer, 2005; Kottman & Meany-Walen, 2018).
Several syntheses of play therapy research (Bratton, Ray, Rhine, & Jones, 2005;
LeBlanc & Ritchie, 2001; Lin & Bratton, 2015; Ray, Armstrong, Balkin, & Jayne,
2015) support the effectiveness of play therapy as a therapeutic intervention for
many different presenting problems, such as reducing clients’ behavioral problems related to aggression, anxiety, conduct disorders, depression, and symptoms
related to Attention Deficit Hyperactivity Disorder (ADHD), such as disruptiveness
and inattentiveness. It also reduces symptoms related to abandonment, autism,
divorce, homelessness, learning disabilities, trauma, and academic or social problems (Abdollahian, Mokhber, Balaghi, & Moharrari, 2013; Blanco & Ray, 2011;
Meany-Walen, Bratton, & Kottman, 2014; Meany-Walen, Kottman, Bullis, & Taylor,
2016; Ritzi, Ray, & Schumann, 2017; Schottelkorb, Swan, Jahn, Haas, & Hacker,
2015; Stulmaker & Ray, 2015).
Adlerian play therapy, theraplay, and child-centered play therapy are all listed on
the National Registry of Evidence-Based Programs and Practices (NREPP), which
is managed by the Substance Abuse and Mental Health Services Administration
(SAMHSA). According to this registry, Adlerian play therapy is deemed effective in
reducing disruptive disorders and behaviors and is promising for building positive
self-esteem. Theraplay is cited as being effective with internalizing problems and is
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promising for clients with autism spectrum disorder and symptoms. Child-centered
play therapy was declared to be promising for improving general functioning and
well-being, in treating anxiety disorders and symptoms, and in treating disruptive
disorders and behaviors.
When deciding whether play therapy interventions are appropriate for specific
children, Anderson and Richards (as cited in Kottman, 2011) proposed that the play
therapist consider the following factors related to the child and his or her issues:
1.
Can this child tolerate, form, and utilize a relationship with an adult?
2.
Can this child tolerate and accept a protective environment?
3.
Does this child have the capacity to learn new methods of dealing with the
presenting problem?
4.
Does this child have the capacity for insight into his or her behavior
and motivation?
5.
Does this child have the capacity for insight into the behavior and motivation
of others?
6.
Does this child have the capacity for sufficient attention and/or cognitive
organization to engage in therapeutic activities?
7.
Is play therapy the most effective and efficient way to address this child’s
problems?
In addition, Anderson and Richards (as cited in Kottman, 2011) recommend
that the play therapist consider the following questions related to his or her own
situation and skills:
1.
Do I have the necessary skills to work with this child? Is consultation or supervision available if I need it?
2.
Is my practice setting devoid of barriers (e. g., not enough space, funding issues,
inadequate length of treatment allowed) that might interfere with effective
treatment?
3.
If effective therapy for this child will involve working with other professionals,
can I work within the necessary framework?
4.
Is my energy or stress level such that I can fully commit to working with
this child?
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If the answers to these questions are yes, and the counselor has no unresolved
personal issues that will negatively impact his or her ability to work with children
and their families, he or she should first explain to the child’s parent(s), caregiver(s),
and/or teacher(s) what play therapy is and how it can be helpful. Additionally, he or
she should work with them on the specific goals for the play therapy process.
GOALS OF PLAY THERAPY
Many children who come to play therapy have a negative self-concept and little
confidence in their own abilities. They may believe they are worthless, unable to
contribute anything positive to relationships, and incapable of taking care of their
own needs. Therefore, one goal of play therapy is to increase children’s sense of
self-efficacy and competence by encouraging them to do things and make decisions
for themselves in the playroom. By demonstrating genuine concern, empathic
understanding, and consistent positive regard, the play therapist can further counteract the negative images about self and others that children have incorporated
into their worldviews.
Most children who come to play therapy have relatively weak problem-solving
and decision-making skills. Thus, another goal of play therapy is to promote these
abilities and to help them learn to accept responsibility for their own behaviors
and decisions.
To summarize, typical goals of play therapy include the following:
1.
Enhance children’s self-acceptance, self-confidence, and self-reliance.
2.
Help children learn more about themselves and others.
3.
Help children explore and express feelings.
4.
Increase children’s ability to make self-enhancing decisions.
5.
Provide situations in which children can practice self-control and
self-responsibility.
6.
Help children explore alternative perceptions of problem situations and
difficult relationships.
7.
Help children learn and practice problem-solving and relationship-building
skills.
8.
Increase children’s feeling vocabulary and formation of emotional concepts.
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In addition to these broad therapeutic goals, counselors may set specific goals
for individual children, depending on the counselor’s theoretical orientation and
the child’s presenting problem (Kottman, 2011; Kottman & Meany-Walen, 2018).
SETTING UP A PLAY THERAPY SPACE
Although Landreth (2012) described an “ideal” space for play therapy, a counselor
who wants to use play therapy with children can accomplish this regardless of what
kind of space is available. Even a small corner of a school cafeteria can work, as long
as others are not using it at the same time in order to ensure client confidentiality.
The counselor must feel comfortable with the space, and if he or she feels safe, happy,
and welcome there, children will sense this and react accordingly (Kottman, 2011;
Kottman & Meany-Walen, 2018).
According to Landreth (2012), an “ideal” play therapy space
1.
measures approximately 12 feet by 15 feet, with an area of between 150 and 200
square feet, which allows children room to move freely but is still small enough
so they will not feel overwhelmed or to stray too far from the play therapist;
2.
offers privacy so children can feel comfortable revealing information and
feelings without worrying about others overhearing them;
3.
has washable wall coverings and vinyl flooring so children can make a mess
without worrying or feeling guilty;
4.
has multiple shelves for storing toys and play materials within easy reach
of children;
5.
has shelves that are secured to the walls so no one can accidentally or purposefully topple them;
6.
contains a small sink with cold running water;
7.
has some countertop space or a child-size desk with a storage area for artwork;
8.
has a cabinet for storing materials such as paint, clay, and extra paper;
9.
has a marker board or chalkboard, either attached to a wall or propped on
an easel;
10.
has a small bathroom attached to the main room;
11.
is preferably fitted with acoustical ceiling tiles to reduce noise;
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12.
has wood or molded plastic furniture designed to accommodate children, as
well as furniture appropriate for the counselor, parents, and teachers;
13.
has a one-way mirror and equipment for observing and videotaping sessions;
and
14.
is located where noise will not present a major problem to others in the building.
TOY SELECTION AND ARRANGEMENT
Landreth (2012), as well as Kottman and Meany-Walen (2018) suggest that the toys and
play materials selected for play therapy should allow for a broad range of emotional and
creative expression, capture childrens’ interest in some way, facilitate their verbal and
nonverbal investigation and expression, and encourage mastery. The toys should help
children establish positive relationships with the counselor (and with other children
if in a group setting), express a wide range of feelings, explore and/or reenact actual
experiences and relationships, test their limits, increase their self-control, enhance
their understanding of self and others, and improve their self-image.
According to Kottman (2011) and Kottman and Meany-Walen (2018), the play
room should include several different categories of toys, including family/nurturing
toys, scary toys, aggressive toys, expressive toys, and pretend/fantasy toys.
•
Family/nurturing toys help children build a relationship with the counselor and
explore family relationships. These toys can also represent real-life experiences.
Examples of family/nurturing toys include such things as a dollhouse and
dolls of different ethnicities (preferably with removable clothing and bendable
bodies), baby clothes, a cradle, animal families, a soft blanket, people puppets,
stuffed toys, sand in a sandbox, pots and pans, dishes and dinnerware, empty
food containers, and play kitchen appliances (such as a sink and a stove).
•
Scary toys allow children to express their fears and learn how to cope with
them. They could include, for example, plastic or rubber snakes, rats, monsters,
dinosaurs, sharks, insects, dragons, alligators, and “fierce” animal puppets
(such as wolf, bear, and alligator puppets).
•
Aggressive toys provide an opportunity for children to express anger and aggression symbolically, find ways to protect themselves from feared objects, and explore
their need for control in various situations. Aggressive toys can include a bop bag,
toy weapons (such as play guns, swords, and knives), toy soldiers and military
vehicles, small pillows for pillow fights, foam bats, plastic shields, and handcuffs.
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•
Expressive toys help children give voice to their feelings, enhance their sense
of mastery, help them practice problem-solving skills, and facilitate their
creative expression. Expressive toys can consist of play materials such as an
easel and paints, watercolors, crayons, markers, glue, newsprint, Play-Doh or
clay, finger paints, scissors, tape, egg cartons, feathers, materials for making
masks, and pipe cleaners.
•
Pretend/fantasy toys allow children to express their feelings, explore a wide
range of roles, experiment with various behaviors and attitudes, and act out
real-life situations and relationships. Pretend/fantasy toys often include things
such as masks, costumes, magic wands, hats, jewelry purses, a doctor kit,
telephones, blocks and other building materials, people figures, zoo and farm
animals, puppets and a puppet theater, a sandbox, trucks and construction
equipment, kitchen appliances, pots and pans, dishes and dinnerware, and
empty food containers.
The playroom does not have to include all these toys. The counselor can provide
an effective vehicle for communication with one or two toys from each category.
Children are highly creative, and they will make the toys they need if they don’t see
them in the playroom. Children readily adapt by pretending that one of the available toys is something else (e.g., a crayon can easily become a magic wand, a gun,
or dinnerware) or by constructing them from available play materials (e.g., making
a doll or a dish from construction paper or pipe cleaners).
Some authors have suggested that toys and play materials should be returned
to approximately the same place after every session (Kottman, 2011; Kottman &
Meany-Walen, 2016, 2018; Landreth, 2012). This structured placement establishes
the play therapy setting as a place where children can count on predictability and
consistency. Arranging the toys and play materials by category, such as placing all
family toys together, facilitates clean-up and helps children remember where to locate
specific toys. Counselors who do not have stationary playrooms can accomplish the
same consistent and predictable arrangement by placing the toys in a specific order
on the floor or on a table in the space that is the current “playroom.” Some play
therapists pick up the toys after the child has left the playroom (Landreth, 2012;
Ray, 2011), whereas others work with the child to clean up the room before the end
of the session and use the cleaning-up process as a time for continuing to build a
collaborative partnership with the child (Kottman & Meany-Walen, 2016).
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BASIC PLAY THERAPY SKILLS
Most play therapists, regardless of their theoretical orientation, use several generic,
basic strategies. These include tracking, restating content, reflecting feelings, returning
responsibility to the child, using the child’s metaphor, and limiting (Kottman, 2011).
TRACKING
In tracking, the counselor describes the child’s behavior to the child to convey that what
the child is doing is important. The ultimate purpose of tracking is to build a relationship
with the child by communicating a caring and connection (Kottman, 2011). When using
tracking, the counselor should avoid labeling objects because an object that looks like a
snake to the counselor might be a whip, a tightrope, a slingshot, or any number of other
things to a child. The counselor should also keep the description of the behavior relatively
vague. For example, a behavior that looks like jumping off a chair to the counselor can,
in the child’s imagination, be leaping out of a burning building, parachuting out of an
airplane, or jumping over a river filled with poisonous snakes. By using pronouns such
as “this,” “that,” “them,” “it,” and “those” instead of specific nouns, and by using vague
descriptions such as “moving over there” and “going up and down” instead of specific
verbs such as “jumping” or “flying,” the counselor allows children to project their own
meaning onto the toys and the actions in the playroom.
Despite the counselor’s descriptions, some children impose their own vision of the
world on things in the playroom. Others simply agree with whatever the counselor
says rather than assert their own version of how things are, or they disagree with
whatever the counselor says rather than appear to comply with the counselor’s version
of how things are. In any case, counselors should reinforce children’s need for freedom
of self-expression. Avoiding labeling is one means to that end. Learn more tracking,
restating content, and reflecting feelings in the Dialogue Box sidebar on this page.
DIALOGUE BOX
The following illustrates tracking, restating content, and
reflecting feelings:
HANNAH: (Dumps several containers of toys into the sandbox)
MRS. MOORE: You put them all in there. [tracking]
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HANNAH: (Filling several toy dishes with sand) All the way to the top!
MRS. MOORE: You filled those up all the way, all the way full.
[tracking]
HANNAH: (Forcefully pushes animals into the containers of sand)
MRS. MOORE: And now you’re pushing those in there, too. [tracking]
HANNAH: They’re all stuck now. They can’t leave!
MRS. MOORE: They are all stuck and can’t leave. You sound happy
that they can’t leave. [restating content, followed by reflecting a
feeling]. You want them to stay there.
HANNAH: (Snatches up one container of sand, spilling some on the
floor. Looks quickly at the counselor.)
MRS. MOORE: You look worried that some of the sand spilled
on accident, and you wanted to check to see if you are in trouble.
Sometimes accidents happen. [reflecting a feeling, followed by
metacommunicating about the meaning of a nonverbal]
RESTATING CONTENT
Restating content involves paraphrasing the child’s verbalizations. Just as with tracking, the purpose is to build a relationship with the child (Kottman, 2011; Kottman &
Meany-Walen, 2018). By conveying to children that what they say is important, the
counselor demonstrates concern and understanding. To avoid parroting the child,
the counselor must use his own words and intonations, as well as vocabulary that
the child understands so that the child feels understood.
Case Example—Miguel
Miguel is an 11-year old boy, referred by his teacher. Miguel’s home environment
is chaotic, and Miguel often assumes responsibility for caring for his two younger
siblings.
MIGUEL: (Gets a piece of paper and the colored pencils and sits down at the
table). “I want to draw today.”
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TERRY: “You knew that you wanted to draw and you got what you needed.”
MIGUEL: (Gets back up from the table.) “I need a regular pencil. (Gets a regular
pencil from the art supplies and examines its eraser). “Good thing I have an eraser.” (Takes a pink school eraser out of his pocket)
TERRY: “You want to make sure you are prepared in case you make a mistake
drawing.”
REFLECTING FEELINGS
By reflecting both children’s’ feelings and the feelings they project onto toys or objects
in the playroom, the counselor can deepen the counselor-client relationship. At the
same time, the counselor helps children express and understand their emotions,
learn more about interactions with others, and expand their affective vocabulary
(Kottman, 2011). With phrases such as, “You seem kind of sad today,” the counselor
can reflect feelings directly. By saying, “It seems like you’re disappointed, Miss
Kitty,” or “The kitty seems really disappointed right now,” the counselor reflects
the feelings of the toys and other objects in the playroom. To help children learn
to take responsibility for their own feelings, the counselor should avoid using the
phrase “makes you feel.” Instead, the counselor should simply state the feeling by
saying, “You feel … .”
The counselor must watch for both the surface, obvious feelings, as well as the
underlying, deeper feelings (Kottman, 2011; Kottman & Meany-Walen, 2018). In play
therapy, deeper feelings sometimes are expressed through the toys and other objects
in the playroom. For example, while watching a child play with a toy cat and mouse,
a counselor may observe that at first the cat seemed happy that he could catch the
mouse, but then he almost seemed disappointed that the mouse didn’t run faster.
The counselor should also look for patterns and interactions between children’s
behavior in the playroom and information the counselor receives about difficulties
outside the playroom. For example, when Nicole stomps into the playroom and takes
a stuffed dog and slams it into the trashcan, she might appear to be simply angry.
The counselor, however, knows that Nicole’s dog died over the weekend and suspects
that she may also be feeling sad and lonely. When reflecting deeper, less obvious
emotions, the counselor should offer a tentative formulation, by saying something
such as “I wonder if you might be feeling a little sad today.” By not imposing his
own viewpoint onto the child, the counselor reduces the possibility of evoking a
defensive reaction from the child.
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When reflecting feelings, as is the case with other interactions, the counselor
must adjust his or her vocabulary to the child’s developmental level (Kottman &
Meany-Walen, 2018; Ray, 2016). Most children (4- to 6-year-olds) seem to recognize four main feeling states: sad, mad, glad, and scared. With these children, at
least initially, the counselor should use only these words and simple synonyms
when reflecting feelings. Children in second and third grades (7- to 8-year olds)
typically have a wider range of feeling vocabulary but still might not comprehend
or express more subtle feelings. Sometimes these children’s receptive vocabulary is
more extensive than their expressive vocabulary. Thus, they may understand words
such as “frustrated,” “disappointed,” and “jealous,” even though they might not use
these words themselves. The counselor expands their affective vocabulary by using a
variety of feeling words to describe subtler affective states. Some fourth-, fifth-, and
sixth-graders (9 to 11-year-olds) have relatively sophisticated feeling vocabularies.
With these children, the counselor might decide to switch to “talk therapy” or use
more structured activities and games rather than play therapy.
Case Example—Anne
Anne is a 5-year old girl, referred by her teacher because she is defiant and has
difficulties getting along with peers. Her mother also reported many behavior
issues at home.
ANNE: (Arranging the toy fencing in a line across the floor.) “This is the dividing
line. (Holding up a small tiger figure.) Her mom and dad told her she’s not supposed to go past this line. It’s dangerous.”
REBECCA: “That (pointing to the fence) is the boundary line and her parents told
her she can’t go past it.”
ANNE: (Sets two larger tiger figures a few feet back from the boundary line, then
picks up the small tiger again and walks it along the inside of the fence, looking
sad.) “She really wants to cross over there.”
REBECCA: “She is thinking about going over there (pointing to the other side of
the fence), and she is kind of sad that her parents don’t want her to go across it.”
ANNE: “She wants to see what’s there. She wants to make a friend.”
REBECCA: “She’s curious about what’s on the other side and thinks she might be
able to find a new friend. I am guessing she might feel a little lonely and she wants
to find a friend.”
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ANNE: (Hops the small tiger over the fence.) “There she goes! She’s going to get
in trouble for that.”
REBECCA: “She was so curious, she jumped over that. She doesn’t seem worried
that she is going to get in trouble.”
RETURNING RESPONSIBILITY TO THE CHILD
The strategy of returning responsibility to the child is designed to increase children’s
self-reliance, self-confidence, and self-responsibility (Kottman, 2011: Kottman &
Meany-Walen, 2018; Landreth, 2012). Returning responsibility can help children
practice decision making, give them a sense of accomplishment, and heighten their
feelings of mastery and control. The counselor can return responsibility for executing
behaviors (e.g., “I think you know how to open the lid to the sandbox yourself”) or
for making decisions (e.g., “You can decide what to paint”).
In the playroom, children are capable of making most decisions that arise, so counselors should usually return this responsibility to the child. When returning responsibility
to a child, however, the counselor has to consider whether the child is capable of accomplishing the task (Kottman, 2011; Kottman & Meany-Walen, 2016). Children can become
discouraged if an adult tells them they can do something that they truly cannot do.
If the counselor is not sure whether children can execute the behavior, he or she can
suggest that they work as a team to accomplish the goal or can ask the child to tell
the counselor “how to do it.” Either way, the counselor allows the child to control the
execution and does not remove responsibility for the behavior from the child.
Several different techniques can be used to return responsibility to a child (Kottman,
2011). In the direct approach, the counselor simply tells the child that he or she is capable
of doing the behavior or making the choice. Additionally, the counselor can employ a less
direct approach, returning responsibility to the child by using (a) tracking, restatement
of content, or reflection of feelings; (b) the child’s metaphor; (c) minimal encouragers
or ignoring the child’s desire for assistance, or (d) the “whisper technique” (Landreth,
1984, personal communication). The following interaction illustrates various types of
responses using these techniques. As the counselor, you would choose the response you
believe is appropriate based on the motivation for the child’s behavior.
Case Example—Yolanda
Yolanda is a 7-year- old who was brought to therapy by her mother after Yolanda’s
father died from a drug overdose. Since her father’s death, Yolanda frequently
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displays helpless behavior at home and at school, wanting adults to do things for
her that she is able to do herself.
YOLANDA: “What’s this?” (asking for help with a decision)
TERRY: “In here, it can be anything you want it to be” (direct response)
or, “ I bet you can figure out what you want it to be.” (direct response)
Another alternative could be, “Mmmmmmmm … . What could it be?” (indirect
response; minimal encourager)
or, “You’re curious about what that could be” (indirect response; reflecting
feelings)
or, “You want me to tell you what that is.” (indirect response; restating content)
YOLANDA: “Open this!” (holding a play-dough container out to Terry)
TERRY: “In here, that is something you can do by yourself” (direct response)
or, “I bet you can figure out how to open that” (direct response)
or, “Mmmmmmmm … . How might this open?” (indirect response; minimal
encourager engaging the child in participating in opening the container together)
or, “You don’t think you can open that by yourself” (indirect response; reflecting feelings)
or, “You want me to open that for you.” (indirect response; restating content)
Refer to the “Now Try This!” sidebar on this page to practice the five different
response techniques for returning responsibility to the child.
NOW TRY THIS!
Antonio is creating a “monster” out of construction paper, Popsicle sticks, and
glue, although a variety of other art materials are available. He is struggling
because the glue he is using is not drying fast enough to hold his project together. Pieces of the monster slide around or fall off when it is handled. Antonio shoves the project at you and angrily says, “You do it. It doesn’t like me.”
How could you return responsibility to Antonio using the five different response techniques? Identify a direct response, an indirect response restating content, a response reflecting feelings, a response using the child’s metaphor, a response using a minimal encourager, and a response using the
whisper technique.
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USING THE CHILD’S METAPHOR OR DESIGNING
A THERAPEUTIC STORY
Much of the communication in play therapy takes the form of metaphor, through
which children express feelings, thoughts, and attitudes and indirectly tell the story
of their situation and relationships through the words and actions of various toys
(Kottman, 2011; Kottman & Meany-Walen, 2018). Sometimes the counselor will
be able to discern the hidden meaning in the play, and at other times the meaning
will be a mystery. The counselor’s willingness to use the metaphor is much more
important than his ability to interpret it. “Using a metaphor” means that the counselor tracks, restates content, reflects feelings, and returns responsibility through the
child’s story without imposing his or her own interpretation of the story’s meaning.
The counselor must exercise self-restraint and avoid “breaking” the metaphor by
going outside the story to the “real” world.
Case Example—Brendan
Brendan is an 8-year old boy who is often aggressive with peers. His mother
reports that he frequently gets in trouble at home and school because he is
defiant.
BRENDAN: (Uses an alligator puppet to bite the dolphin puppet, then grabs the
handcuffs.) “He’s going to jail!” (Handcuffs the alligator puppet to a chair leg
away from the other puppets.)
REBECCA: “He’s going to jail because he bit the other animal. You’ve hooked him
up there. He’s not able to get away.”
BRENDAN: “There (gesturing to the alligator). He can’t be around the other animals because he is bad and always hurts them.”
REBECCA: “Sometimes he hurts the other animals. You think he is bad because
he does that. You put him over there so he won’t be around the others. Then he
can’t hurt them.”
BRENDAN: (Makes small crying noises and inches the alligator toward the other
puppets but the handcuffs hold it back). “He wants to be with them, but they
don’t like him because he’s mean.”
REBECCA: “He sounds sad, making those little crying noises. He wants to be with
the others. I wonder if his feelings get hurt when he thinks the others don’t like
him. I wonder if he wants them to like him.”
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BRENDAN: “He does want them to like him. (turning to Rebecca) Do you think I
should let him out of jail?”
REBECCA: “You get to decide if he gets out of jail. If you’re worried that he might
do something wrong again, maybe we could figure out a way together to help
him.”
The counselor can also design a therapeutic metaphor for the child, read a book
designed as a bibliotherapy intervention, or retell a story the child told to help the
child gain insight into one of his or her maladaptive patterns or to teach an adaptive skill for solving problems or interacting with others (Kottman, 2011; Kottman
& Meany, 2016, 2018). It is helpful for the counselor to use characters in the story
(or in the book being read to the client) that are similar to the characters the child
uses in his or her stories. The counselor can even strengthen the therapeutic relationship with a child by co-telling stories together, taking turns narrating the story
after the counselor has set up the characters and the beginning of the story. Learn
more about therapeutic metaphors by referring to the “Add This to Your Toolbox”
sidebar on this page.
ADD THIS TO YOUR TOOLBOX
One intervention is to create a metaphoric story that can help the child
work toward a particular goal using a metaphor from the child or creating
one of your own. You can tell the story to the child or act out the story using
things such as puppets or figures. To develop a metaphoric story, follow
these steps:
1. Decide the goal of the story based on what you know about the child.
2. Dislocate the story in time and place (i.e., a jungle, a desert, a long time ago).
3. Describe the characters (animals, people, or fairy tale characters): a protag-
onist (who represents the child), an antagonist (who represents the person
or situation contributing to the difficulties), and often a helper figure and/
or ally (representing the counselor and others who can provide support).
4. Take the protagonist through the problem, making progress dealing with
obstacles, and eventually finding a resolution.
5. Have the characters celebrate and affirm changes in the protagonist and
what was learned.
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SETTING LIMITS
Limiting, or setting limits in the playroom, protects the child and the counselor from
harm, increases the child’s sense of self-control and self-responsibility, and enhances
the child’s sense of social responsibility (Gonsher, 2016; Kottman & Meany-Walen,
2018; Landreth, 2012). Appropriate limits in play therapy are those intended to
keep children from (a) physically harming themselves, other children, and/or the
counselor; (b) deliberately damaging the play therapy facility or play materials;
(c) removing toys or play materials from the play therapy setting; (d) leaving the
session before the scheduled time; and (e) staying in the session after the time limit
has expired. Imposing other limits (e.g., not aiming a toy gun at the therapist, not
pouring unlimited amounts of water into the sandbox, not jumping from the furniture onto the floor) depends on the individual counselor, the setting, and the client.
Counselors seldom come into the first session with a long list of rules outlining
“appropriate” playroom behavior. Most wait to set a limit until a child is about to
break one of the playroom rules. In this way, the counselor can avoid inhibiting
the timid, withdrawn child or challenging the acting-out child who likes to get
into power struggles. Many different strategies can be used for setting limits in
play therapy (Kottman, 2011). One widely used method involves the following four
steps (Landreth, 2012):
1.
Reflecting the child’s wishes, desires, and feelings (e.g., “You’re really mad and
would like to shoot me with the dart gun.”)
2.
Stating the limit in a nonjudgmental manner, using a passive voice formulation
(e.g., “I’m not for shooting.”)
3.
Redirecting the child to more appropriate behavior (e.g., “You can shoot the
dart at the target or the big doll.”)
4.
Helping the child express any feelings of anger or resentment at being limited
(e.g., “I can tell you’re really mad that I told you I am not for shooting.”)
Kottman and Meany-Walen (2016) describe another method of setting limits, in
which the child is engaged in redirecting his or her own inappropriate behavior.
This strategy also has four steps:
1.
Stating the limit in a nonjudgmental way that reflects the social reality of
the play therapy setting. (e.g., “It’s against the playroom rules to shoot darts
at people.”)
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2.
Reflecting the child’s feelings and guessing about the purpose of his or her
behavior. (e.g., “You’re feeling kind of mad at me; you want to show me that I
can’t tell you what to do.”
3.
Engaging the child in redirecting his or her behavior by asking for suggestions
for more socially appropriate behavior choices (e.g., “I’ll bet you can think of
something you can shoot that won’t be against the playroom rules.”) In many
cases the child will come to an agreement with the counselor about appropriate
behaviors and will abide by that agreement, so the counselor will not have to
take further action. If the child chooses to break the agreement, however, the
counselor would move to the fourth step.
4.
Setting up logical consequences that the child can enforce (e.g., “You didn’t
stick to our agreement about not shooting me with the dart gun. We need to
think of a consequence just in case you decide to shoot the dart at me again.
What do you think would be a fair consequence?”). Examples of consequences
are putting the dart gun on the shelf for a short time, having to put the dart
gun away for the rest of the session, or leaving the session before it is over.
THEORETICAL APPROACHES TO PLAY THERAPY
O’Connor (2011), co-founder of the Association for Play Therapy, suggests that “therapists can be effective only when they consistently work from an organized theoretical
framework” (p. 254). There are many different theoretical approaches to play therapy,
some of which are based on major models of counseling and psychotherapy (i.e.,
Adlerian, person-centered, cognitive-behavioral, Gestalt, Jungian, narrative, object
relations, psychodynamic, and integrative-prescriptive) and others that were developed
specifically for play therapy (i.e., experiential play therapy, release play therapy, ecosystemic play therapy, and theraplay). It is beyond the scope of this chapter to describe
each approach in detail, so the following approaches, which are on a continuum from
non-directive to directive (Kottman, 2011, Yasenik & Gardner, 2012), will be addressed:
child-centered play therapy, which represents the nondirective end of the continuum;
Adlerian and cognitive-behavioral play therapy, both of which combine nondirective
and directive elements and represent the middle of the continuum; and theraplay,
which represents the directive end of the continuum. For more in-depth coverage of
the various theoretical orientation, please refer the following: Crenshaw and Stewart
(2015); Kottman and Meany-Walen (2018); Kottman and Schaefer (1993); Landreth,
2012; O’Connor and Braverman (2009); and O’Connor, Schaefer, and Braverman (2016).
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CHILD-CENTERED PLAY THERAPY
In developing nondirective, child-centered play therapy, Virginia Axline (1969)
applied the basic concepts of client-centered therapy developed by Carl Rogers (1961).
Axline (1969) delineated the following principles for practitioners of client-centered
play therapy:
1.
The therapist must build a warm, friendly, genuine relationship with the child
to facilitate a strong therapeutic rapport.
2.
The therapist must be totally accepting of the child and have no desire for the
child to change.
3.
The therapist must develop and maintain a permissive environment that
encourages the child to feel free in exploring and expressing emotions.
4.
The therapist must constantly attend to the child’s feelings and reflect
them in a way that encourages the child to gain insight and increase
self-understanding.
5.
The therapist must respect the child’s ability to solve problems if the child has
the opportunity and the necessary resources. In so doing, the therapist must
remember that the child must be completely responsible for decisions about
if and when to make changes.
6.
The therapist must follow the child’s lead in play therapy. The responsibility
and privilege of leading the way belong solely to the child.
7.
The therapist must be patient with the therapy process and not attempt to
speed it up.
8.
The therapist must set only those limits essential for connecting the play therapy to reality.
In the words of Landreth and Sweeney (2009),
child-centered play therapy is a philosophy resulting in attitudes and behaviors
for living one’s life in relationships with children. It is both a basic philosophy of the innate human capacity of the child to strive toward growth and
maturity and an attitude of deep and abiding belief in the child’s ability to
be constructively self-directing (p. 123).
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Practitioners have found that children’s behavior in child-centered play therapy
goes through the following five distinct phases (Landreth & Sweeney, 2009):
1.
Children use play to express and diffuse negative feelings.
2.
Children use play to express ambivalent feelings, usually anxiety or hostility.
3.
Children again express mostly negative feelings, but the focus has shifted to
specific targets—parents, siblings, or the therapist.
4.
Ambivalent feelings (positive and negative) resurface but now are targeted
toward parents, siblings, the therapist, and others.
5.
Positive feelings predominate, but the child expresses realistic negative attitudes in appropriate situations.
In child-centered play therapy, “the therapeutic relationship offered by the therapist is the essential feature of the intervention. The therapist’s ability to provide
a relationship and environment conducive to the child’s growth is the primary
concern of therapy” (Ray & Landreth, 2015, p. 5). The counselor’s main function
is to provide the child with the core conditions of unconditional positive regard,
empathic understanding, and genuineness. Client-centered play therapists believe
that by communicating acceptance and belief in the child, they can activate the
child’s innate capacity for solving problems and moving toward optimal living.
Child-centered play therapists depend on tracking, restating content, reflecting
feelings, returning responsibility to the child, and setting limits. They avoid skills that
lead the child in any way, such as interpretation, design of therapeutic metaphors,
bibliotherapy, and other directive techniques.
ADLERIAN PLAY THERAPY
In using Adlerian play therapy (Kottman & Ashby, 2015; Kottman & Meany-Walen,
2016), counselors combine the principles and strategies of Alfred Adler’s individual
psychology (Adler, 1954, 1958) with the basic concepts and skills of play therapy.
Professionals who practice Adlerian play therapy conceptualize children through
Adlerian constructs and communicate with them through toys and play materials.
Adlerian play therapy has four phases (Kottman, 2011):
1.
In the first phase, the counselor builds an egalitarian relationship with the
child, using tracking, restating content, reflecting feelings, returning responsibility to the child, encouraging, limiting, answering questions, and cleaning
the room together.
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2.
In the second phase, understanding the child’s lifestyle, the counselor uses
the play interaction, the child’s metaphors, art techniques, sand tray, play
therapy activities, and dance and movement exercises to gain an understanding of the child’s lifestyle (personality traits and orientation toward
self, others, and the world). The counselor formulates hypotheses based on
the information gathered in the second phase to guide the process in the
third and fourth phases.
3.
In the third phase, the counselor helps the child gain insight into his or
her lifestyle by using metaphors, stories, artwork, sand trays, role-playing,
metacommunication, and so forth. In metacommunication, the counselor
communicates about the communication taking place within the relationship
to help the child notice/understand his or her patterns of communicating.
4.
Finally, in the fourth phase, the counselor provides reorientation and reeducation for the child, which may involve direct and indirect teaching designed
to help the child learn and practice more adaptive skills and attitudes.
In Adlerian play therapy, consultation with parents, caregivers, and teachers is
essential, and the process with them is parallel to that of play therapy. In the first
phase, the counselor builds a relationship with the important adults in the child’s
life. During the second phase, the counselor explores the adults’ lifestyles and their
perception of the child’s typical ways of interacting with others. During the third
and fourth phases, based on an understanding of the child and the adults in his
or her life, the counselor helps parents and teachers gain insight into the child’s
patterns and his or her own lifestyle. Finally, the counselor teaches parenting skills
to parents and classroom management skills to teachers (when appropriate). Read
about one professional’s approach to play therapy in the “Voices from the Field”
sidebar on this page.
VOICES FROM THE FIELD—PROFESSIONAL
When I am working with a play therapy client, one of my first goals is to learn
about his or her passions. I have found that using clients’ passions to connect
and relate to them can be very beneficial. Sometimes, this means that I have to
acquire some new knowledge about a topic. If a client really likes a certain kind
of music, then I listen to some songs in that style. If a client likes video games, I
try to play some of the games he or she likes. During the early phase of therapy, I
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relate to the client’s passion in order to set the foundation for building the therapeutic relationship. In later phases, I try to use the client’s passion when creating
therapeutic interventions. By doing this, I am able to connect what happens in
my office to the outside world.
—Neal, agency counselor
COGNITIVE-BEHAVIORAL PLAY THERAPY
Cognitive-behavioral play therapy (CBPT) developed by Susan Knell (1993a, 1993b,
2009, 2016), combines cognitive and behavioral strategies within a play therapy
delivery system. Using interventions derived from cognitive therapy and behavior
therapy, cognitive-behavioral play therapists integrate play activities with verbal
and nonverbal communication.
Knell (2009) delineates six specific principles essential to CBPT:
•
The counselor involves the child in the therapy through play. The child is an
active partner in the therapeutic process.
•
The counselor examines the child’s thoughts, feelings, fantasies, and environment. Rather than being client focused, CBPT is problem focused.
•
The counselor helps the child develop more adaptive thoughts and behaviors
and more effective strategies for solving problems.
•
The counselor uses specific behavioral and cognitive interventions that have
empirical support for efficacy with specific problems.
•
The counselor designs interventions using baseline and follow-up measurements
of behavior to provide empirical support for the effectiveness of treatment.
•
CBPT is structured, directive, and goal oriented.
Cognitive-behavioral play therapy consists of four stages: assessment, introduction/
orientation to play therapy, middle stage, and termination (Cavett, 2015; Knell; 1993a,
2009). During the assessment stage, the counselor employs formal and informal
instruments to gather baseline data about the child’s current level of functioning
and level of development; the presenting problem; and the attitude of the parent(s),
caregiver(s), and the child about the presenting problem and their understanding
of it. As part of this process, the counselor may use parent report inventories (e.g.,
child behavior checklist, Achenbach, 1991), clinical interviews, play observation,
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cognitive/developmental scales, and projective assessment methods (e.g., the puppet
sentence completion task, Knell & Beck, 2000).
In the next phase, introduction/orientation to play therapy, the counselor provides parent(s) with an initial evaluation of the child based on the data gathered
during the assessment stage (Knell, 2009, 2016). Then, the counselor and parents
collaborate in devising a treatment plan that includes outcome goals and treatment
strategies. During the middle stage of CBPT, the counselor combines play activities
and interactions with specific cognitive and behavioral intervention techniques
(including modeling, role-playing, and behavioral contingency) to teach children
more adaptive behaviors for dealing with specific situations, problems, issues, or
stressors. In addition, the counselor uses strategies that help children generalize
their new skills to situations and settings in the “real” world. One of the main
functions of the counselor during this phase is to compare the child’s current
functioning with his or her baseline functioning and assess the child’s progress
toward therapeutic goals.
During the termination stage, the counselor helps the child develop plans for
coping with various situations after counseling ends. The counselor uses behavioral
techniques to reinforce changes in the child’s thinking, feeling, and behaving and
encourages the child to practice strategies for generalizing the progress made in the
playroom to other relationships.
THERAPLAY
Theraplay, developed by Ann Jernberg (Jernberg & Booth, 1999), is defined as “an
engaging, playful treatment method modeled on the healthy, attuned interaction
between parents and their children: the kind of interaction that leads to secure
attachment and high self-esteem. It is an intensive, relatively short-term approach
that actively involves parents in order to improve the parent-child relationship”
(Bundy-Myrow & Booth, 2009, p. 315). Although this definition specifically mentions parents, theraplay is an appropriate intervention for improving the relationship
between a range of caregiver types (i.e., foster parents, kinship carers, etc.) and their
children. Theraplay is built on the following core concepts (Booth & Winstead,
2015, 2016):
•
Interactive and relationship-based experiences
•
Direct here-and-now interaction
•
Adult guidance (in sessions and at home)
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•
Attuned, empathic, and reflective responsiveness
•
A preverbal, social, right-brain focus
•
Multisensory experiences, emphasizing touch
•
A playful attitude
Theraplay is a directive, intensive, and brief process that uses no conventional
toys or art supplies (Booth & Winstead, 2015, 2016; Jernberg & Booth, 1999; Munns,
2011). Usually, the counselor meets first with the parents/caregivers for an initial
interview and assessment of the parent/child relationship, using the Marschak
interaction method (MIM) (Marschak, 1960). They then meet again so the counselor can explain the theraplay philosophy, begin to build rapport with the parents,
provide feedback from the initial assessment, and develop a treatment plan in
collaboration with them. This session is followed by 8 to 12 theraplay sessions, half
an hour each, involving the child and parents. In the standard arrangement for
theraplay work, each session has two counselors. The theraplay counselor works
directly with the child, and the interpreting counselor works directly with the
parents. During the entire 30 minutes of the first four theraplay sessions and the
last l5 minutes of each of the remaining sessions, the parents and the interpreting
counselor observe the interactions of the child and the theraplay counselor from
behind a one-way mirror or from a corner of the playroom. The interpreting counselor describes to the parents what is happening between the theraplay counselor
and the child and suggests ways in which they can use the theraplay dimensions
demonstrated in the sessions in their everyday interactions with the child. Starting with the fifth theraplay session, the parents and the interpreting counselor
join the child and the theraplay counselor in the play during the last 15 minutes
of each session so the parents/caregivers can practice the theraplay dimensions
under the counselor’s supervision.
Healthy parent-child interactions serve as the model for the directive theraplay
dimensions of structure, challenge, engagement, and nurture (Booth & Winstead,
2015, 2016). Play therapists following this approach use activities and materials that
facilitate these dimensions to remedy problems in the attachment process that create
intrapersonal and interpersonal struggles for children (Booth & Winstead, 2015,
2016; Jernberg & Booth, 1999; Munns, 2011). Counselors demonstrate the dimension
of structure by setting limits and clear rules for safety and by employing experiences
that have a beginning, a middle, and an end (e.g., singing games) and activities that
are designed so that the parents structure the experience (e.g., having the parent
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draw something and asking the child to draw something just like what the parent
has drawn). The dimension of challenge is facilitated, for example, by helping the
child take an age-appropriate risk to strengthen the child’s sense of mastery and
self-confidence (e.g., the parent teaches the child something new and encourages
the child to practice it). Counselors exhibit the dimension of engagement when, for
example, they engage the child in playful, spontaneous interactions to show the child
that the world is fun and stimulating and that other people can be simultaneously
exciting and trustworthy (e.g., blowing bubbles together or tickling one another). To
facilitate the nurture dimension, counselors initiate interactions designed to soothe,
calm, quiet, and reassure children by meeting their early, unsatisfied emotional
needs. These interactions include, for example, feeding, making lotion handprints,
or swinging them in a blanket.
Theraplay counselors are constantly active and directive. They do not talk much.
Instead, action is the focus of theraplay sessions. The theraplay counselor plans
activities and materials that facilitate the various dimensions of each session and are
tailored specifically to the needs of the individual child. The counselor decides how
much time during the session to spend on each dimension based on the problems
and interactional patterns of the child and his or her family. During the session,
the counselor may change or adapt some of the activities in response to the child’s
attitude and/or reactions to the therapeutic process (Bundy-Myrow & Booth, 2009;
Jernberg & Booth, 1999).
The interpreting counselor’s role is both verbal and directive. During each theraplay
session with the parents, the counselor explains the interaction between the child
and the theraplay counselor, makes suggestions regarding activities that could help
the child at home, comments on how specific theraplay dimensions could enhance
the parent-child relationship, coaches the parents when they participate in activities,
and provides support and encouragement when the parents begin to incorporate
the theraplay dimensions in their parenting.
MULTICULTURAL IMPLICATIONS FOR PLAY THERAPY
Play can be a powerful therapeutic intervention across cultural lines, provided that
the therapist engages in cultural humility throughout his or her work with multicultural clients. Some theoretical approaches to play therapy, such as Adlerian play
therapy and ecosystemic play therapy naturally take into account multicultural
issues because they view children within their environment. Such theories consider
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the effect of the social and political climate on marginalized people and cultures.
Although some models incorporate such a view, all play therapists must engage
in active reflection and consideration of the role culture plays in the therapeutic
process, regardless of their theoretical orientation (Gil & Drewes, 2006; Post &
Tillman, 2015; VanderGast, Post, & Kascsak-Miller, 2010). Supervision, professional
case consultation, and regular self-reflection are necessary pieces of multicultural
play therapy, as every therapist comes to the work with his or her own perceptions,
biases, and stereotypes that affect his or her work.
The play therapist can set the stage for culturally competent services by first
incorporating toys within the playroom that represent a variety of cultures (Chang,
Ritter, & Hays, 2005). This may include figures with different skin tones, sand tray
miniatures related to different religions, and enough color options in the art materials to create an array of skin colors. The setup of the playroom is meant to convey
a message that the playroom is a place for all children. The availability of toys and
books depicting diverse cultures, ethnicities, races, genders, and religions sends
a specific message to children from different cultures that this is a playroom that
recognizes them just as they are. It is a subtle message, but powerfully welcoming.
It is important to choose toys that are not solely based on stereotypes. For example,
it would not be appropriate to have sand tray miniatures/figures that only depict
African American males as “thugs” or “gangsters” or all figures of Natives Americans portraying the traditional “cowboy versus Indian” stereotype. While it may
be appropriate to have a few such representations, the child needs accessibility to a
variety of images.
Viewing the child, the family, and the presenting problem within the context of
the family’s culture is a key component of providing effective multicultural play
therapy services (Post & Tillman, 2015). The therapist needs to remain aware that
play themes and symbols may have different representations within different cultural
contexts. There also may be cultural differences regarding appropriate social interactions, particularly with authority figures, medical professionals, and/or experts.
The family may view the therapist in any of these roles, even if the therapist does not
consider him- or herself as such. Examine your own cultural biases in the “Personal
Reflections” sidebar.
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PERSONAL REFLECTION
We bring our personal experiences, stereotypes, and biases into the playroom with us. We all carry internal records about groups, including our own.
We may have out-of-awareness biases about a specific group of people
that can color our professional interactions with clients and families. While
each of us takes our values and biases into the playroom, it is essential to
make sure they do not have a negative impact on the relationship with play
therapy clients. It is essential for all counselors to become aware of these
values and biases.
Try this exercise. Think about a specific group of people from the following categories. Notice the first thoughts that pop into your mind about
this group. It is important not to filter yourself. If you filter what you think
because it is not polite or because you are embarrassed, you will not be
accessing your biases, which are your unfiltered responses.
•
Specific racial and/or ethnic groups
•
Religious groups
•
Family structures
•
Sexual orientation/gender identity
•
Age groups
•
Parental issues (i.e., substance use, criminal history, abuse)
WORKING WITH PARENTS AND TEACHERS
Parents and caregivers can be valuable allies for counselors who work with children,
and it is very important to invite them to participate in the play therapy process,
either as part of family play therapy sessions or through consultation. We want to
clearly recognize that “parents” come in a variety of both biological and non-biological forms. Caregivers provide a valuable perspective, regardless of the formal title
that describes their relationship to the child. Play therapists often find themselves
working with children in complicated caregiving situations, such as involving both
a foster parent and a biological parent in play therapy sessions for an individual
child. Depending on the situation, both the foster parent and biological parent
may be involved separately in sessions, or even together, if deemed appropriate to
meet the child’s needs. Kinship caregivers, who are related to the child (i.e. adult
siblings, grandparents, extended family members), can also be included in the play
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therapy process. Family play therapy sessions involve at least one family member
entering the play room with the child for the session, which may include nondirective
play, directive play, or a combination of both, depending on the counselor’s theory.
During consultation, the counselor can ask questions to gain more information,
answer questions that the caregiver has, provide suggestions to help the caregiver
in understanding the child and in meeting the child’s needs, and offer general
encouragement and support.
Since teachers are also influential in a child’s (and adolescent’s) functioning, it is
also helpful to include them as a part of the play therapy process. Teachers can serve as
consultants who know a lot about the clients’ time at school and about their families.
Consultation with teachers can involve the same types of interactions as described
with parents. The counselor can maximize the effects of the play therapy process by
helping parents and teachers delve into the problems underlying the young client’s
issues and enhance their understanding of what is really going on with the child, as
well as teaching them to make shifts in their interactions with the child, (Kottman,
2011; Kottman & Meany-Walen, 2018). Learn more about a parent’s experience with
the play therapy process by reading the “Voices From the Field” sidebar.
VOICES FROM THE FIELD—PARENT
Debbie, mom of Sam (age 6): “I started bringing him because I wanted him to
change, but I think more than anything, I have changed because I’ve been in the
sessions and I’ve seen how what I do affects him … . Play therapy has helped me
to see things how he sees them. It’s like you say something to him about what we
are doing, but it has a completely different meaning to me … . I don’t have to be
the perfect parent with the perfect kids and I can still be a great parent with great
kids … . If anything, I’ve learned to be flexible with my expectations of the four
kids based on their different ages but also my expectations of myself. I’ve learned
to relax and have fun with them. When I’ve been able to do that, his behaviors
have been fewer and farther between. We are both calmer and happier.”
TRAINING AND EXPERIENCE REQUIRED
FOR PLAY THERAPISTS
Counselors cannot learn how to conduct play therapy effectively by reading books or
attending a workshop or two. This approach to counseling children requires an entirely
different mind-set than talk therapy. To make the paradigm shift from thinking
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about words and verbal interactions as the primary modality for communication to
thinking about play and toys as the primary modality for communication takes concentrated training and practice. The Association for Play Therapy provides guidelines
for registration or certification as a professional play therapist that include educational
requirements and clinical experience. (See www.a4pt.org for the list of requirements.)
TAKE-AWAYS FROM CHAPTER 4
As we conclude this chapter, we would like to refer to the vignette at the beginning
of the chapter and share what we learned from working with this client, as well as a
technique we used that we think was effective. When Malachi entered play therapy,
he was displaying a number of issues, including negative thoughts about himself and
strong beliefs that adults would not take care of him or keep him. Because his anxiety
was so high, I (Rebecca) quickly learned that I had to be flexible in working with
Malachi. I adjusted my intervention style to provide him structure to help lower his
anxiety and use activities that interested him and with which he could be successful.
A technique that I thought was effective in working with Malachi was using the
child’s metaphor. Malachi created the metaphors through his play and utilized the
same metaphoric themes throughout his time in therapy. These metaphors became a
safe way for Malachi to explore and process his thoughts, feelings, and experiences.
Had I broken the metaphor or directly addressed Malachi’s thoughts/feelings he
would not have been able to listen to what I said, let alone develop the insight that
would allow him to grow. The metaphor provided distance so that he could see me
as talking about the metaphor instead of me talking about him, which could have
been too painful.
After reading this chapter, you now should be more knowledgeable about these
key points:
•
Different client populations who may be appropriate candidates for play therapy
•
The logistics of setting up a play therapy space and selecting toys and materials
•
How to utilize basic play therapy skills (including tracking, reflecting content/
feelings, returning responsibility to the child, using the child’s metaphor, and
setting limits)
•
The basic components of different theoretical orientations and their application
to the play therapy process
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•
Multicultural considerations in the play therapy process
•
Including parents, caregivers, and teachers in the play therapy process
•
Training and supervision required for play therapists
•
Research support for play therapy
HELPFUL WEBSITES
Association for Play Therapy
www.a4pt.org
Center for Play Therapy, University of North Texas
http://cpt.unt.edu/
Substance Abuse and Mental Health Services Administration (SAMHSA),
National Registry of Evidence-based Programs and Practices
https://nrepp.samhsa.gov/landing.aspx
Centers for Disease Control and Prevention, Child Development
https://www.cdc.gov/ncbddd/childdevelopment/
PRACTICAL RESOURCES
Crenshaw, D., & Stewart, A. (2015). (Eds.), Play therapy: A comprehensive
guide to theory and practice. New York, NY: Guilford.
Green, E. J., & Myrick, A. C. (Eds.) (2015). Play therapy with vulnerable populations: No child forgotten. Lanham, MD: Rowman & Littlefield.
Malchiodi, C. A., & Crenshaw, D. A. (Eds.) (2014). Creative arts and play therapy for attachment problems. New York, NY: Guilford.
Sweeney, D. S., Baggerly, J. N., & Ray, D. C. (2014). Group play therapy: A
dynamic approach. New York, NY: Routledge.
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CHAPTER 5
Solution-Focused Brief Counseling
Russell A. Sabella
“We can’t solve problems by using the same kind of thinking we used
when we created them.”
Albert Einstein (1879–1955), German-Swiss-American theoretical
physicist
LEARNING OBJECTIVES
1.
To recognize the differences between “solution talk” and “problem talk”
2.
To identify the unique principles, assumptions, and techniques of solution-focused
brief counseling that distinguish it from problem-centered approaches
3.
To describe how to move young clients from an external to an internal explanation of progress.
M
r. Callahan is a middle school counselor who meets with seven students as
part of a divorce adjustment group. Although heterogenous in gender, grade
level, and ethnicity, these students have several things in common: their
parents have all divorced within the last 8 months, their grades are declining, and,
according to their teachers, they have been disruptive, withdrawn, or unresponsive
in the classroom.
Mr. Callahan spent the first meeting engaging students in several icebreakers and
team-building activities. He explained that the purpose of the group was for members
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to support each other and find ways to deal with the stressors and adjustments
resulting from their parents’ divorces. During the second meeting, he noticed that all
participants seemed sad and were rather irritable, so he asked them what was going
on. They all took turns sharing how awful the week had been, especially as it related
to their new circumstances and challenges. Each of their stories seemed worse than
the last, as if they were trying to outdo each other about how terrible things were
because of the divorce. Mr. Callahan worked diligently to help them vent and when
he thought the time was right, he began to help them problem solve. He asked, “What
do you think you can do to deal with these changes and stressors?” When the group
members heard the question, they apparently homed in on the words changes and
stress, which prompted them to think of other ways that, according to their perceptions, the divorce had irrevocably damaged their lives. They even began to engage in
fortune telling, delineating how their futures were going to be more problematic as
a result of this family disruption. This pessimism persisted throughout the second
meeting and well into the third, at which point Mr. Callahan began to realize that
he was having trouble getting them to “come out of the shadows,” so to speak. He
wondered how he could change their mood and outlook, even in the face of new
and unfamiliar challenges. Frustrated and worried, he thought to himself, “How
can I get these kids to step up and start making chicken salad out of chicken s**t?”
The purpose of this chapter is to present information about the basic principles
and practices of solution-focused brief counseling (SFBC) and its applications with
children and adolescents. In addition, this chapter will describe how SFBC can
be applied in classrooms and small groups, and in consultation with parents and
teachers.
WHAT IS SOLUTION-FOCUSED BRIEF COUNSELING?
Solution-focused brief counseling (SFBC; also known as solution-focused brief
therapy (SFBT) is a future-focused, goal-directed approach to counseling/therapy
that highlights the importance of searching for solutions rather than focusing on
problems (Proudlock & Wellman, 2011; Sklare, 2014; Trepper, Dolan, McCollum,
& Nelson, 2006). It is a strengths-based approach, emphasizing resilience and
resources that individuals possess and how these can be utilized to pursue goals
and enact purposeful and positive change (Corcoran & Pillai, 2007). At the heart
of the solution-focused approach is the invitation to clients to develop a detailed
picture describing their lives when what they hoped to gain from counseling has
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been achieved and to understand that this picture is not determined by the problem that brought them to counseling (Ratner, George, & Iverson (2012). Clients
are encouraged to think about times when their problems did not exist, how these
times contributed to better situations, and how to recreate such circumstances
in their present situations. The primary focus of this type of counseling model is
on young clients’ strengths and abilities rather than on their weaknesses. Finally,
because they find their own solutions to problems, self-confidence often increases.
With this emphasis on solutions rather than problems, counseling is also typically
briefer (Murphy, 2008; Sklare, 2014).
Solution-focused brief counseling was originally inspired by the work of a husbandand-wife team, Steve de Shazer and Insoo Kim Berg, along with their associates at
the Brief Family Therapy Center in Milwaukee. According to Bannink (2006), de
Shazer, Berg, and their colleagues advanced the SFBC model based on the premises
developed by Bateson (1979) and Watzlawick, Weakland, and Fisch (1974), who
believed that the attempted solution often perpetuated the problem and did not
solve it, and that insight into the origin of the problem was not always necessary.
WHY ADOPT AN SFBC APPROACH?
SFBC is one of many counseling theories that counselors can use to help children
and adolescents get back on track, working toward appropriate goals. Several theories such as behavioral, systemic, cognitive behavior and rational-emotive behavior
therapy have proven to be effective with this population, although no single theory is
effective and appropriate for all young clients in all situations. (Norcross & Beutler,
2008; Norcross & Goldfried, 2005). SFBC is an elegant, flexible, and comprehensive
approach that stands out as a well-established best practice, both in clinical counseling
and especially as part of a comprehensive school counseling program. In addition,
SFBC is a forerunner for counseling approaches that are becoming more integrative.
Other SFBC features, perhaps not exclusive but certainly integral, are that SFBC
•
is consistent with the professional counseling value of a stronger collaborative
relationship with clients, students, consultees, and families;
•
incorporates greater use of inherent individual and family strengths and less
reliance on outside resources. It is a humanistic model of empowerment;
•
has a strong empirical basis demonstrating significant improved outcomes
for children and families (Gingerich, Kim, & MacDonald, 2012; Trepper &
Franklin, 2012);
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•
is empowering for the counselor as well as the child. Counselors who engage
in solution-focused work report that they are energized by implementing this
strength-based focus and process (Sklare, 2014);
•
is culturally responsive and relevant because it focuses on young clients’ experiences within their own frames of reference, not the counselor’s (Sklare, 2014);
•
reduces the risks associated with diagnosis and confidentiality. When the
counselor focuses primarily on solutions and exceptions, the need for and the
importance of diagnosis and confidentiality are greatly reduced; and
•
is briefer in duration and therefore appeals to school counselors and administrators, students, as well as to mental health counselors who work with time
constraints imposed by insurance companies.
BASIC ASSUMPTIONS OF SFBC
Every counseling theory includes basic assumptions about people, problems, and
priorities, which form the framework of the theory. Solution-focused brief counselors
assume the following (Corey, 2017; Sklare, 2014):
•
Young clients have the capacity to act effectively. This capacity, however, is
temporarily blocked by a negative focus, especially sustained by thoughts
and feelings.
•
Young clients are the experts. They determine the goal and the way to achieve it.
•
Small changes lead to bigger changes. Goals and solutions do not necessarily
have to be equally matched to the intensity, frequency, and duration of a presenting problem. Small steps in the right direction can quickly help students/
clients reach a “critical mass” of achievement, tipping the scales toward progress.
•
Understanding causation does not necessarily lead to resolution. The solution-focused counselor can help children and adolescents resolve problems
without ever fully understanding the cause or nature of it.
•
A solution is not necessarily related to the problem. Analysis of the problem is
not useful in finding solutions, whereas analysis of exceptions to the problem
is. That is, the SFBC counselor helps clients analyze and methodically examine
positive exceptions and hypotheticals.
•
There are exceptions to every problem. Many exceptions originate from the
client, whereas others originate from support systems. It is important to
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encourage individuals in the support systems to find effective ways to help
the young client.
•
Change happens. Children and adolescents want to change. They have the
capacity to do it and they do their best to make change happen.
•
Change is unique. Just as each individual is unique, so is every solution.
•
Change is inevitable. Change is a continuous process, whereas stability is an
illusion. The question is not whether, but when change will occur. Talking
about past successes is effective in steering change toward greater success.
•
Perception matters. There are many ways of looking at a situation, all
equally correct.
THE BASIC GUIDELINES FOR SFBC
Solution-focused brief counseling generally occurs in four to six meetings and is
guided by several core principles that are imperative to elicit positive behavioral
changes (Sklare, 2014), including the following examples:
•
If it works, don’t fix it … do more of it. If it works just a little, build on it. If
it doesn’t work, do something different. That is, when you find yourself in a
hole, stop digging and look for the way out. More of the same leads nowhere
(Berg & Miller, 1992).
•
Focus on what is right and is working (solutions) rather than what is wrong
and what isn’t working (problems).
•
Always maintain positive expectations that things will change for the better,
even though there will be setbacks. Remember to look for overall net gains.
•
To discover or reach a solution, it is not necessary to analyze or understand the
problem, especially the causes. It is, however, necessary to analyze exceptions
and hypotheticals of the problem.
APPLICATIONS OF SFBC
The versatility of the SFBC approach extends to a variety of issues, populations, and
formats. SFBC has been used successfully to help enhance high school students’
self-esteem (Taathadi, 2014), build a sense of psychological coherence among female
adolescents (Namani, Baqaei, & Pardakhti, 2016), decrease behavior problems, and
increase academic performance (Franklin, Biever, Moore, Clemons, & Scamardo,
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2001; Kim & Franklin, 2009). SFBC has also been used in parent training programs
(Carr, Hartnett, Brosnan, & Sharry, 2017) and with high-risk adolescents (Selekman,
2017). Sklare (2014) dedicated an entire chapter in his book, Brief Counseling That
Works: A Solution-Focused Therapy Approach for School Counselors and Other Mental
Health Professionals, to describing examples of how the SFBC principles and techniques have been applied and integrated into play counseling (e.g., using puppets and
sand trays) group counseling, classroom management, parent-teacher conferences,
and self-led guided imagery.
THE NATURE OF THE COUNSELING RELATIONSHIP
Solution-focused brief counselors work within a collaborative model of interaction
and take a social-constructionist approach. They do not consider themselves experts
and they do not assume that they know more about a client’s life than the client does.
Solutions are not scientific puzzles (such as unraveling the meaning of DNA codes)
that practitioners solve, but rather changes in perceptions, patterns of interacting
and living, and meanings that are constructed within the client’s frame of reference
(Berg & De Jong, 1996; de Shazer, et al., 1986).
In SBBC, the counselor and client co-construct solutions. More specifically, the
practitioner’s role in the solution-focused process is to invite young clients to explore
and define two matters: (a) what they want to be different in their lives (goals) and
(b) what strengths and resources they possess or can develop to make these desired
differences a reality. The practitioner affirms and amplifies clients’ definitions of
goals, past successes, strengths, and resources as they emerge through conversation.
Consequently, these conversations focus more on building solutions than on solving
problems (Berg & De Jong, 1996).
The solution-focused counselor does not worry too much about first developing
rapport for counseling to begin because the basic helping conditions such as trust,
respect, empathy, and genuineness are inherent in the model. Solution-focused brief
counseling embodies many of Carl Rogers’s humanistic principles. The focus on
client-driven goals and utilizing clients’ strengths and key words, their belief systems, and theories of change supports the therapeutic relationship and the success
of SFBC (Selekman, 2005). In fact, many SFBC counselors do not start a meeting by
first getting to know the client, but by getting right to work and asking the question,
“As a result of working together, what is one thing that you would like to be able to
do better?”
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PROBLEM ASSESSMENT
Solution-focused practice is conducted in the same way regardless of the presenting
problem. According Berg and DeJong (1996), “Unlike most other forms of therapy,
solution-focused counseling does not assume a necessary connection between a
client’s problem and its solution. Consequently, assessment and related interventions
play a smaller role (p. 387). Even at the intake phase of counseling, evidence suggests
that there is no difference in outcomes regardless of whether you focus on problems
or solutions (Richmond, 2007). This is in contrast to conventional wisdom that purports that a “comprehensive psychological intake interview or assessment, in which
information is gleaned from a broad array of areas, is essential to determine the
client’s appropriateness for counseling and plan a successful course for treatment”
(Richmond, 2007, p. 1). In the SFBC model, problem assessment is mostly replaced by
solution assessment (exceptions and hypotheticals). It is important to remember that
“…staying at the surface level of problems” should not be equated with
being superficial in the treatment process, because even though the treatment process avoids going “deep” into the problem, it helps clients to do
something attainable and observable in their present and immediate life
context. Solution-focused brief counseling acknowledges that we cannot
change the past but assumes that we can do something helpful in the present” (de Shazer, 1994, as cited in Lee 2013, pg. 6).
THE INDIVIDUAL COUNSELING PROCESS
The SFBC therapeutic process is unique in several ways. First, SFBC relies on a therapeutic process which is heavily embedded in the type and nature of dialogue the
counselor and the client (McKergow & Korman, 2009). Consequently, solution-focused
counselors and clients engage in a process that involves them talking about themselves and their challenges in new and different ways in a co-constructivist manner.
Co-construction is a collaborative communication process where at least two parties
work together to produce information, which, changes meanings and interactions. The
principles of this conversational process between counselor and client are the same,
and always focus on what clients want to do differently, now and in the future. In this
model, words influence perception and focus which is the main engine of change.
Second, the SFBC approach to dialogue as the essential therapeutic process focuses
on what is observable in communication and social interactions between the child
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or adolescent and counselor. This commitment to systematic observation as the
basis of what is and is not useful in SFBC dates back to its origins at the Brief Family
Therapy Center (BFTC) in Milwaukee.
Third, SFBC was developed empirically as part of studies conducted in language
use in dialogue, providing a solid experimental basis in contemporary psycholinguistic research (Bavelas, 2012). Thus, the SFBC evidence base was founded in basic
research and the theoretical developments were then used in a family therapy clinic
where these communication processes were further refined in the processes of brief
psychotherapy (SFBTA, 2013).
COUNTDOWN TO SOLUTIONING—SIX GENERAL
TECHNIQUES
Several years ago I decided that I needed a way to better organize all the different
aspects of this model, especially as it pertained to training others. I realized that
the different features of the model fall nicely into a countdown, starting with six
essential techniques that are practiced throughout the process and procedures of
the solution-focused model: detailing, mind mapping, mine fielding, cheerleading,
amplifying, and reframing or refocusing. Let the countdown begin!
Detailing
Detailing helps young clients and other stakeholders to clarify behaviors and thoughts
that have either been helpful in the past (exceptions) or will be helpful in the future
(hypotheticals). Detailing helps to clarify “what” has worked better in the past or
will be working better in the future. Solution-focused detailing questions include,
for example, the following:
•
As a result of us working together, what will you be doing better or different?
•
What were you doing when you were more on track that would help explain
that things were better?
•
What were you telling yourself during the times that you felt more confident?
•
What have others noticed you doing that lets them know that you’re having
a good day?
•
If I were to video record you doing more of what works, what would I see that
lets me know it’s time to press the record button?
•
What will you be doing/thinking that we would see as the next sign of progress?
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•
How do you describe the change that you are looking for?
•
When things are going better, what will your parents notice you doing differently?
Detailing helps the child or adolescent better envision the behaviors and
thoughts that contributed to better times. Details also help them more tangibly
and clearly describe another part of the model, mind mapping, which has them
describe the “how’s” of their more desirable choices, behaviors, and thoughts. In the
­solution-focused brief counseling approach, the more detailed the better. Detailing
is also one of the three main criteria for developing solution-focused goals, which I
will describe in number 3 of the countdown. This part of the model is so important
that falling short of describing detailed behaviors and thoughts typically results in
an impasse. Table 5.1 illustrates insufficient and more effective detailed statements.
TABLE 5.1 Detailing Statements
Insufficiently
detailed statements
Solution-focused
More effective detailed
question
statements
When things were
better, I used to
study more.
What exactly were you doing while you were studying
that would help explain that
you are better?
I was bringing my books home,
writing down my assignments,
and taking notes while I was
reading.
When I get to a 4
on the scale, I’ll be
better behaved.
What will your teacher
notice you doing that will let
her know that you are better
behaved?
I’ll be raising my hand more,
looking at her, and waiting my
turn for answering the
question.
I’ll be paying
attention better.
What will your eyes, ears,
and hands be doing when
you are paying better attention?
My eyes will be looking at
the teacher, my hands will be
folded, and my ears will be
listening.
I’ll get better
grades.
When you were getting
better grades, what were
you doing that helped you
to do better in your class?
I was doing my homework
more often (Note: This one is
still not detailed enough. Need
to ask what are the behaviors
and thoughts that contributed
to the student doing more
homework).
I will be feeling
more confident
about … .
When you are feeling more
confident, what is it that
you’ll be doing better or
different as a result?
I’ll be smiling more, talking
to more people, and I’ll be
happier.
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Mind Mapping
If you are an educator, you will recognize mind mapping as a common approach to
lesson planning and delivery. In teaching, mind mapping helps students brainstorm
and explore ideas, concepts, or problems. In the context of curriculum, mind mapping can help students better understand the relationships and connections between
ideas and concepts. This idea is similar in solution-focused counseling, consultation,
and conferences. Solution-focused mind mapping starts with a central idea, usually
a desirable behavior or thought, and then helps students delineate connections and
understandings of similar behaviors and thoughts, particularly those that helped
contribute to the solution. Another way to describe mind mapping is that this procedure helps students develop a mental image or map to better visualize the “how’s”
of getting to the “what’s,” either in the past in the form of exceptions, or in the future
as hypotheticals. Mind mapping also helps the student focus on the behaviors and
thoughts that they are capable of, can control, and for which they are responsible.
Examples of solution-focused mind mapping questions include the following:
•
How did you make that happen for yourself?
•
Wow, how do you do that?
•
How did you motivate yourself to … ?
•
Knowing how sad and overwhelmed you feel, how is it that you were able to
get out of bed this morning and make it to our appointment?
Mine Fielding
It has been said, “It’s not going to be easy; it’s going to be worth it.” Students and
clients achieve goals and make progress even in the face of adversity, challenges,
and obstacles. In fact, many of life’s greatest lessons are learned by overcoming fears
and struggles. How does this happen? Solution-focused mine fielding helps young
clients clarify how they have achieved or have been more on track even though it
was difficult. For example, after clients describe how they got from point A to point
B on their mind map, we, as counselors, let them know that there were “mines,”
along the way. Mines are metaphors for threats to their progress (barriers, adversities,
challenges) which have the potential to “blow them off course.” It is important that
the counselor helps clients and students recognize how they avoided stepping on
them and “blowing themselves up.” This is an often-overlooked focus and underrated
part in all of counseling. In fact, I believe that entire meetings or sessions should be
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about helping children and adolescents discover and eventually recreate the type
of resilience or grit that they have already shown when tackling problems. When
exploring hypothetical solutions, mine fielding can help them anticipate obstacles
and develop plans for overcoming them.
Examples of solution-focused mine field questions include the following:
•
How did you make that happen for yourself even when it was difficult?
•
That can’t be easy; how do you cope?
•
How did you do that even though you didn’t feel like it?
•
How do you explain that you are getting more on track even when your (external) challenges remain?
•
With all the terrible things going on with you, how do you manage to … ?
Cheerleading
The purpose of cheerleading is to provide encouragement, support, and reinforcement for client accomplishments. Accomplishments can be in the form of attempts,
efforts, or achievements, to name a few. Counselors should cheerlead any movement
toward progress, no matter how small, either in the past or when detailing the future.
Sprinkling in some cheerleading can help advance clients’ confidence and motivation.
Effective cheerleading can simply be a show of admiration, an enthusiastic tone of
voice, or a direct compliment. According to Sklare (2014), it is also important not to
patronize clients when cheerleading. In other words, SFBC practitioners should truly
mean what they say; otherwise, their comments will appear insincere and negate everything that has been accomplished in the counseling session. Cheerleading will come
across as more sincere when the specific reasons for the compliments are included
in the cheerleading response. Another tip is to include your own feelings, which
demonstrates the impact that the client is having on others. Several examples follow:
•
You went to your music lesson yesterday; now you’re getting it!
•
You came to school today, even though it was not easy. I knew you could do it!
•
You studied hard, did your homework, and I’m very excited about your progress!
•
You just told me about how you are going to be more on track; I’m
very encouraged.
•
Even though you felt like fighting, you got yourself to stay calm, that’s fantastic!
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One criticism of cheerleading, especially among frustrated teachers or parents,
may be that you are getting excited over behaviors that children should be doing
throughout the normal course of a day anyway, such as bringing a pencil to class
or writing down assignments. My personal opinion is that although teachers are
not wrong, if we keep doing what we’ve always done, we keep getting what we’ve
always gotten. So, if a student has not been bringing a pencil to class and now starts
to do it, we should cheerlead and reinforce that as a “baby step” toward other goals
or bigger achievements.
Amplifying
Picture someone throwing a small pebble into a pond and watching the ripple effects.
In solution-focused counseling, amplifying helps clients identify small goals and
intensify them into larger goals, thus creating a behavioral ripple effect. Amplifying
includes three parts:
1.
After detailing what the client has done or will be doing that demonstrates he or
she is reaching goals or is more on track, identify who has noticed. For example,
ask, “How has your dad noticed that you are coming home on time more often
this week than before?” or, “Have your parents noticed that you have turned
off your cell phone during dinner time more often this week without being
asked?” At this point, there will probably be an opportunity for more detailing.
For example, you can ask, “What exactly has your dad noticed you doing that
would help explain that you are doing better at getting home on time?”
2.
Explore the impact on the other person. Ask, “What difference does it make
to your dad now that you are coming home on time more often?” or, “What
difference does it make to your parents that you turn off your cell phone
during dinner without them having to ask?” Basically, we are establishing that
clients do not live on an island or in a vacuum. Instead, what they do impacts
others. With a solution-focused approach, we can more readily focus on how
they positively impact others when they are behaving more responsibly and
appropriately. This may be in stark contrast to a problem-centered approach
whereby the primary focus might be on how the child or adolescent is having
a negative impact. Another way to ask the amplifying question in this step
is, “How is your dad’s life better because you are on time more often?” One
possible answer is that the father is able to go to bed earlier and is happier
because he got a good night’s sleep.
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3.
Explore how a positive change in the other person translates to a positive
change in the client’s life. Ask, “How does the fact that your dad is getting
more sleep making a difference for you?” The client might say that things are
better at home because his or her dad seems happier and isn’t nagging at him
or her to get home on time.
Amplifying is sometimes also referred to as asking reciprocal relationship questions (Sklare, 2014). These questions help clients envision how others would respond
to changes in their behavior and, in turn, how a change in someone else’s behavior
motivates changes in them. The effect is a “spiraling up” of progress, not only for
clients, but for the entire support system.
Other questions that elicit amplifying are as follows:
•
“When was the last time you and your dad had ‘quality time’ together? Tell
me more about that time. What were you doing? What was he doing? What
did you talk about? What did you say? When he said that, what did you do
next? What did he do then? What else was different or better about that time?
If he were here, what else might he say about that time? How was that better
for you?”
•
“Who noticed this change in you? How is life better for him or her because
you changed? How does that make a difference for you?”
Reframing and Refocusing
Reframing is expressing something a client has said in a different way so as to alter
the frame of reference and ultimately the focus. The words we use determine our
perceptions and our perceptions shape our realities. For example, if an adolescent
says, “Some days it’s really hard to come to school because of what’s happening,”
the counselor might say, “So, some days you have to muster the strength and courage to come to school.” One of the most common opportunities for reframing in
the solution-focused model is going from negative goals to positive goals; that is,
helping them talk about what they want to be able to do better or differently rather
than what they wish they were doing less. In behavioral terms, this is explained
as helping children and adolescents increase the frequency and duration of the
desired behaviors instead of helping them extinguish undesirable behaviors. A
powerful word to help make this shift is “instead.” For example, “You say you
don’t want to fight with others so much. It sounds like you want to be able to get
along better with others instead.” Or, “You’re telling me that you are sick of being
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tired, and, instead, you would like to have more energy.” Remember, one of the
assumptions of the solution-focused model is that people get more of what they
focus on, so it is important to help them reframe their complaints and wishes into
achievable goals.
In addition to making statements or asking reframing questions, using the solution-focused hypothetical such as a classic miracle question helps to achieve a shift
in focus. So, when a client says that he needs to work on his negative attitude, the
counselor might ask, “And suppose you started to have a more positive attitude,
what would you be doing better or different that lets us know that you are being
positive?” Or, in the case of wishing that others would change, the counselor might
ask, “When the other person changes, what will you be able to do better or different
for yourself?” Reframing and refocusing is a step toward goaling, one of the five
general steps described next.
FIVE GENERAL STEPS IN SFBC
Sklare (2014) describes five general steps, implemented in sequence, for practicing
solution-focused brief counseling. However, based on my own experiences, trying
to practice solution-focused brief counseling in a stepwise manner is a bit constricting. In fact, I think you can start with any one of these five areas or even focus an
entire session on only one or two of them. Later in this chapter, I will recommend
that counselors might want to start with scaling and then incorporate all the other
steps, especially if you are a beginner and just starting to develop proficiency in
implementing the solution-focused approach.
GOALING
Goaling helps clients formulate effective solution-focused goals. Solution-focused
goals should meet at least three criteria (discussed in greater detail later in the
chapter): They are detailed, they are in the presence of an action, and they are in the
client’s control. The very first question in a solution-focused meeting can start the
goaling process: “What would you like to be able to do better or different as a result
of working together?” Other goaling questions include the following:
•
What would be the next sign of progress?
•
What will you be doing to make that change happen more often?
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•
What did others notice you doing that let them know you are now more on
track? What else? What will others see you doing that lets them know you
are more on track?
•
Not everyone with your anger issues can manage it. What advice would you
give to someone else with the same difficulty?
•
What does
(teacher or parent) expect as a result of you being
in counseling? What do you hope happens as a result of our time together?
EXCEPTIONS
One of the assumptions of SFBC is that every problem has discernible exceptions
that can serve as the basis for present and future goals. As a detective might do, the
solution-focused counselor helps the client rediscover clues to solutions by exploring
times when things were better. Again, the counselor must stay focused on those
actions that, in the past, led to success.
HYPOTHETICAL
This pathway to change helps children and adolescents imagine life as if the goal were
already achieved and then take small steps to accomplish that goal in the present.
It is important that the counselor focus on actions that are in the client’s control.
For example, if a client describes a future where she is no longer being bullied, the
counselor must refocus on a different behavior because whether someone is bullying her is really not in her control. The counselor might ask, “And if the bullying
were to slow down or stop, how would life be better for you? What will you be able
to do or think better as a result?” Then, the counselor begins to help her do those
things even though the bullying may continue, such as act “as if.” Of course, in this
example, the counselor is also ethically obligated to work with the perpetrator and
appropriate others to prevent the bullying from occurring again.
The hypothetical is classically approached in the form of a miracle question.
According to de Shazer (1985),
“The miracle question has been asked thousands of times throughout the
world. It has been refined as practitioners have experimented with different
ways of asking it. The question is best asked deliberately and dramatically:
Now, I want to ask you a strange question. Suppose that while you are sleeping tonight and the entire house is quiet, a miracle happens. The miracle is
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that the problem which brought you here is solved. However because you are
sleeping, you don’t know that the miracle has happened. So, when you wake
up tomorrow morning, what will be different that will tell you that a miracle
has happened and the problem which brought you here is solved?” ( p. 5.)
The miracle question involves young clients making a leap of faith and imagining
how their lives will be changed when the problem is solved. This is not easy, especially for young children and adolescents because they have to make a dramatic
shift from problem-saturated thinking to focusing on solutions. Most students
and clients need time and assistance to make that shift (De Jong & Berg, 2013),
and they may require an alternative form of expressing the answers to the miracle
question. For example, some young children can better describe their hypothetical
by drawing, using puppets, or acting it out in a role play. Whether verbal means
or more creative methods, here are several questions to consider when exploring
the hypothetical:
•
“What will be the first thing you notice that would tell you that a miracle has
happened and that things are different?”
•
“What might others (mother, father, siblings, friends, teachers) notice about
you that would tell them that the miracle has happened, that things are different or better?”
•
“When have you have seen pieces of this miracle happen?”
•
“What’s the first step that you will begin to take to make this miracle happen?”
THE MESSAGE
Usually at the end of the first session (individual or group), the counselor writes
the client a message that includes three parts: (a) two to three compliments about
his or her motivation, efforts, positive goals, etc.; (b) a summary of the general
client wishes (this part is also known as a “bridge”); and (c) an assignment for
doing more of the tasks or goals identified in the meeting. Tasks do not necessarily
need to incorporate new behaviors, thoughts, or attitudes, but may include doing
more of what is already working. Tasks can include doing some small part of the
hypothetical solution or miracle or preparing for future meetings by “being on
the lookout” for exceptions to problems, observing for future progress, or discovering how “spontaneous” exceptions are happening. Refer to Figure 5.1 for a
sample message.
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The Solution Focused Message
Compliments
Bridge
Tasks
Dear June,
I was impressed with how you stayed in your seat and
practiced staying calm even when you were angry. I am
encouraged that this will get easier for you with more
practice. I’m inspired by your hard work.
Because you want to pass the class and eventually
be a Vet ...
Practice deep breathing, tell yourself “It’s not worth
it,” and “check in” with me at the end of the period.
FIGURE 5.1 Solution-focused message.
SCALING
Scaling questions invite children and adolescents to perceive their current situation
along a continuum. The process of scaling (described in much more detail later)
involves rating how they are currently doing on a scale from 1 (when things have
been at their worst) to 10 (when their problems are resolved and they are adequately
back on track). After rating themselves, the counselor and client explore progress
that has already been made, and then they may explore future progress when things
are 10% better and when they are approaching their miracle. The advantages of
scaling include that it
•
provides a baseline of how the client is doing;
•
sets the stage for exploring progress already made (solutions);
•
is an excellent way to initiate the counseling process when you as the counselor
don’t know what else to do. This is especially effective to get clients to open up
when they are not thrilled to be in counseling;
•
helps clients “step outside” their experience for a while, getting a birds-eye
view of their status;
•
is easy for clients to follow. In fact, after doing it several times with the counselor, clients often begin scaling on their own without any prompting; and
•
helps in establishing manageable, realistic, and achievable steps in the
counseling process.
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FOUR WAYS TO MOVE FROM COMPLAINTS AND
WISHES TO GOALS
Complaining about their lives helps clients feel better, but it does not help them
get better. Wishing that others will change is just that—a wish that may or may
not come true. Therefore, when clients only complain or wish that something will
change, counselors should acknowledge this desire but eventually move them in
a more productive direction. Exceptions do exist, such as when a child lives in a
household with abusive or irresponsible parents or when an adolescent is being
harassed, humiliated, or bullied. In these situations, the counselor should continue
working with the client to help him or her cope with the situation and succeed
where possible, despite his or her circumstances. At the same time, however, it
is imperative that the counselor become an advocate by teaming with other professionals and addressing and resolving the external complaint. When necessary
and appropriate, the SFBC model has at least four methods for refocusing and
reframing from the negative to the positive, from an external focus to an internal
one, including being direct, exploring a change in the student without a change in
others, exploring the preferred future or hypothetical, or challenging the assumptions of the problem.
BE DIRECT
When appropriate, the counselor may simply let the client know, for example, “There
is nothing that you or I can do right now that will change your teacher’s behavior.
I’m wondering what I can help you do better for yourself right now?”
EXPLORE A CHANGE IN THE CHILD OR ADOLESCENT
WITHOUT A CHANGE IN OTHERS
The counselor can help the child or adolescent explore the parts of the solution that are
not necessarily connected to the original complaint. Based on the previous example,
the counselor might say, “I’m not sure that your teacher will change or be fired or
retire. That may or may not happen. If it did, it could take a while. So, knowing that
you want to do better, how are you going to succeed and achieve anyway?” When I
use this technique with students, I often witness a non-verbal jarring expression on
their faces, perhaps because they are recognizing for the first time that their success
is not completely dependent on others, even their teachers.
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EXPLORE THE PREFERRED FUTURE HYPOTHETICAL
Another way to move from wishes and complaints to goals is to explore the preferred future. The counselor may say, “Suppose your parent (or teacher) behaved
more to your liking; what is it that you will be able to do, even just a little bit better,
as a result?” Then, the counselor helps the client focus on one or two small steps
or goals described in the hypothetical. This is a classical “acting as if” or “fake it
‘til you make it” scenario. That is, as they begin to “try on” a new role or behavior
(i.e., act differently), they begin to feel and think differently, and, ultimately, they
become different. When others see the difference, they too will begin to respond
differently and somewhat conform to the new reality. I call this “flipping the script”
in counseling.
CHALLENGE ASSUMPTIONS
This one is a bit trickier than the others, although it can be a very powerful way to
refocus from problems to preferred futures. There are three steps:
1.
You begin by emphasizing fluctuations and soliciting symptoms of the problem (which is a bit counterintuitive in this model). Let’s say that a client
presents with depression. The counselor would say, “Adolescents who are
suffering from depression experience different problems. I wonder how
depression has been a problem for you?” The client might report he or she
is having trouble sleeping, eating, getting out of bed, socializing, or doing
homework, for example.
2.
After the client has described his or her symptoms (and after you have sufficiently been facilitative), it’s time for the big reframe. The counselor might say,
“And so when you are getting better, we will be able to know that because you
will be sleeping better, eating better, socializing with others more, and doing
your homework, right?”
3.
Pick the behavior that the client has the most control over and has the greatest
potential for a “ripple effect” or impact. Then, focus on that behavior: detail,
mind map, mine field, cheerlead, and amplify it. The counselor might say,
“When you were feeling better and socializing more, who were you with? What
were you doing? How did you make it happen? What challenges did you have
to overcome to make that happen? Who noticed? What difference did it make
to them?” … and so forth.
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Within a few minutes, you will notice that the focus is not on the presenting
problem (depression) but more on exceptions and hypotheticals (socializing with
others in the past and in the future).
THREE CRITERIA FOR EFFECTIVE
SOLUTION-FOCUSED GOALS
After years of supervising students and professional counselors, one thing that
I’ve learned is that when counselors are feeling stuck, often the culprit is that the
goals did not meet all three criteria for effective solution-focused goals. Even if only
one criteria isn’t met or addressed, counselors will likely feel frustrated. Although
previously mentioned, let’s focus on these three criteria in more detail. Remember,
when using the SFBC model, goals must be in the presence of a behavior or thought,
detailed or measurable, and in clients’ control.
IN THE PRESENCE OF A BEHAVIOR OR THOUGHT
Like many counseling models, clear, concrete, and specific goals are important
components of SFBC. As previously described, clients are encouraged to frame
their goals as the presence of a solution rather than the absence of a problem.
For example, rather than the goal being “We would like our son to stop cursing
at us,” a better goal is “We want our son to talk more politely to us.” This goal
would need to be described in greater detail. Also, if a goal is described in terms
of its solution, it can be more easily scaled (Trepper et al., 2008). Remember, one
of the SFBC assumptions is that people get more of what they focus on, so by
focusing on the presence of solutions instead of the absence of problems, clients
are more apt to get more of what they really want. For example, many people
have experienced how this works while dieting—they are more likely to succeed
if they focus on the foods they can eat rather than avoiding the foods that they
should not eat. So, if they are trying to avoid eating donuts but they are thinking
about them, they are more likely to look for them and eat them. Instead, the solution-focused dieter focuses on fruits, vegetables, and other healthy foods instead
of the donuts.
DETAILED OR MEASURABLE
Goals should be measurable so that there is tangible evidence that the goal was
accomplished. A solution-focused question that I like to ask to get more details is,
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“If I were to come to your class or house and watch you study, what would I see
that lets me know that you are doing it?” Examples of details as they relate to academic achievement or studying might include bringing a pencil to school, looking
at the book, taking notes, and asking questions in class. Whenever possible, the
solution-focused counselor elicits smaller realistic and reasonable goals rather than
larger ones that may overwhelm the client and causes him or her to give up because
the goal seems unachievable.
IN CLIENTS’ CONTROL
As previously mentioned, people can only change what they can control. Oftentimes,
a change in one person’s behavior leads to changes in others’ behavior, but there are
no guarantees. No matter how passionate a client is about getting someone else to do
something better, it simply may not be possible because it is out of his her control.
As the counselor, you can offer to approach the other person, but the focus for now
must be on what the student or client can control. For example, if a client complains
about being lonely and his or her goal is to have more friends, that is not completely
in anyone’s control. Therefore, as counselors we can help the client learn better social
skills but explain that it is actually up to others to decide to meet them halfway or not.
Once the goal is established, it’s time to detail, mind map, mine field, cheerlead,
amplify, scale, and so forth. It is also worth mentioning that all goals must be appropriate. Borrowing from choice theory (Glasser, 1965), goals should also meet the
three R’s: be right, realistic, and responsible. Also worth noting is that these solution-focused criteria for effective goals are not new, as other models include these
criteria and more. For example, you may already know about SAMIC3, an acronym
for simple, attainable, measurable, immediate, consistent, controlled by the client,
and committed to by him or her. Another popular and very similar acronym used
especially in education is SMART. SMART goals are specific, measurable, achievable,
results-focused, and time bound.
RESULTS-FOCUSED AND TIMEBOUND
Other tips for establishing effective solution-focused goals include, whenever possible, that the goal should be in the process form, which usually includes the “how”
and “-ing” terms (e.g., “How will you be doing this?”). Such phrasing implies that
the child or adolescent will be working toward solutions. Second, counselors should
communicate their belief in the client’s ability to develop solutions by using the term
“you,” which they can do by asking, “What will you be doing when this happens?”
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Solution-focused brief counseling focuses primarily on the past in the form of
exceptions and on the future in the form of hypotheticals. Overall, the primary
focus is to do more of what is working (or what will be working in the future). This
model is about focusing, building momentum, planning, and empowering, with
the goal being to do more of what works. This seems oversimplistic, although it is
actually highly challenging when a child or adolescent is focused on problems, issues,
deficits, barriers, and weaknesses. Probably the most overused cliché of all time is
the definition of insanity, which is to keep doing the same thing while expecting
different results. This resonates with all of us, and for good reason.
Now that you have read about the basic assumptions of SFBC, refer to the “Personal
Reflection” sidebar that will help you clarify your own beliefs about this approach.
PERSONAL REFLECTION
In this chapter you read about becoming more solution focused in your
work as a counselor. The assumptions and guidelines seem to be a bit counterintuitive to what you might normally believe from a problem-solving perspective. How do you think you might effectively make this paradigm shift?
Do you really believe that people can recover and resolve issues without
ever really knowing, understanding, or focusing on how things went wrong
in the first place? If you were the client, how do you think you would experience solution-focused brief counseling?
WHERE DO I START?
When you step back and look at the big picture, you realize that the SFBC approach
includes many options. The model’s flexibility, although a positive feature for the
experienced SFBC counselor, can leave a beginner uncertain and maybe a bit overwhelmed as to where to begin. Throughout my years of teaching SFBC, I’ve noticed
that people who are just starting to become more solution focused have a better
handle on the model when they start with scaling, because of all the techniques,
it is one of the most straightforward and structured. Furthermore, scaling acts as
an umbrella for all the other techniques. Throughout scaling, “we aim for small
changes that will represent progress in the direction of goals and preferred outcomes”
(Bertolino & O’Hanlon, 2002, p. 4). Following are more details about the steps in
solution-focused scaling.
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SCALING TOWARD SOLUTIONS
Step 1: Present the Scale and Ask for a Number
The counselor begins by describing a scale from 1–10 where each number represents
a rating of the client’s complaint(s). The counselor might say, “On a scale of 1 to 10,
with 1 being the worst this problem has ever been, and 10 being the best things could
be, what number would let me know how you are doing right now?” In this step, it’s
important not to get bogged down with too much detail. In my experience, the client
may want further clarification and ask questions such as, “What do you mean, like,
give you a number for how I’m getting into trouble?” You can (and should) keep it
general at this step and reiterate, “… just a number that lets me know how things
are going here at school or at home.”
If you believe that the number is inaccurate, especially if it is too high for the
current reality, simply accept it as if it were true. If clients can explain how they
determined their given number, even if you believe it is inflated, they are more apt
to move toward that higher number. So allow them to “shoot for the stars and at
least land on the moon.” This is more effective than challenging clients about their
skewed perceptions and distortion of reality. Remember, this is their reality.
For this step, you can use different types of scaling tools. You can simply draw
a line on a piece of paper and make hash marks indicating placeholders for each
number. Or, you can be more creative and use ladders, yardsticks, thermometers
that range from zero (cold) to 100 degrees (you are getting hot), football gridirons
(zero is just getting started and 100 is a touchdown), or bar charts, for example (refer
to this website to download various SFBC scaling templates: schoolcounselor.com/
handouts/.
Step 2: Explore Progress Already Made
This is the biggest and most important step in the solution-focused scaling process,
but many counselors tend to give this step a nod or skip it altogether. Once the
clients give you a number, let’s say a 3, many counselors feel the urge to have them
explain the obvious problems and issues that must exist when one is only at a 3. Or,
they provide help and skip exploring strategies for getting to a 4 or even higher. By
doing this, they rob clients of the benefit derived from focusing, in detail, on the
strengths, efforts, resources, and achievements already in play that they should be
doing or using more often. At the same time, clients usually report that they feel
more hopeful and empowered during this time of inventorying what is right as
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compared to what is wrong. For example, if a client chooses a 3, the process is just
beginning and it is time for detailing, mind mapping, mine fielding, cheerleading,
amplifying, and reframing, when necessary. If a client choses a zero, solicit a number
that describes a time when he or she was doing better and put the focus on this
number by asking, “What number would you give yourself when you were at your
best?” Or, you can share your amazement about how he or she has been able to do
so much already, such as get out of bed, get dressed, comb his or her hair, and go
to school—all at a zero!
Step 3: Explore Future Progress
After you have sufficiently explored what progress your client has made, you can
begin to explore future progress. In the third step, ask, “What will you be doing
better or different when you get to the next number (or 10% higher)?” The key to
this step is to assume that there has been progress and to help the client describe,
in detail, his or her behavior at the new number. In particular, emphasize what the
client can control and the presence of positive behaviors, thoughts, and feelings
instead of the absence of these. Ask questions such as the following:
•
If I were to video record you when you are at a 4 (the next number on the
scale), what will you be doing that lets me know that I should start recording?
•
What will others (e.g., parents, friends) see you doing that lets them know you
are now at a 4? What might they say or do to when they notice that you’re better?
•
How will your life be better when you are at a 4?
You may decide to ask the classic “miracle question” (as previously described)
at this point to solicit future progress. If a client decided that he or she is at a 10,
although you believe further progress is needed, you can continue the process by
simply asking, “What would you say you will be doing better or different if the
scale went to an 11? Don’t worry, it’s your scale; you can change it if you want.”
To finish, decide together on two to three behaviors that the client will be doing
more or differently when 10% progress is made. The behaviors may include already
existing behaviors that the client will do more of, old behaviors not currently practiced, or new behaviors or skills developed in the course of counseling. These will
become the goals. As a reminder, make certain that each goal meets the criteria
for well-established goals: in clients’ control, in the presence of an action (positive),
and very detailed and clear.
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In addition to scaling with a young client, you may choose to simultaneously
scale with another caretaker, such as a teacher or parent. If the client agrees, ask
the teacher, for instance, to provide a number that indicates his or her perception of
how the child is doing. If the teacher’s number is lower than the student’s, ask the
student, “What are you doing that, if your teacher were to better notice, he or she
would give you a higher number? How will you be doing this better so that your
teacher will notice?” If the teacher’s number is higher than the student’s, ask, “What
is the teacher noticing about you that you probably have not recognized for yourself?”
The focus should be on what the client wants more frequently, more intensely, or
over a longer duration. You have certainly heard the expression, “Practice makes
perfect?” Well, I’m not sure about perfect, although practicing an unfamiliar skill
can make it better. Refer to the “Now Try This!” sidebar for instructions about how
to practice this skill.
NOW TRY THIS!
Now that you’ve learned about how to do solution-focused scaling, give it
a try! Start with an individual client and, instead of trying to do the entire
process, just practice the first couple of steps. Introduce the scale, solicit
a number, and then spend the rest of the time exploring progress already
made. Resist temptations to solve the problem or focus on future achievements. Stay in the present and enjoy having your client inventory what he
or she has been able to accomplish thus far. Spend time detailing, mind
mapping, mine fielding, cheerleading, amplifying, and reframing when necessary. As a result of doing this, how do you feel? Do you think these skills
are effective?
SUBSEQUENT MEETINGS: PUTTING ON YOUR
SOLUTION FOCUSED EARS
Insoo Kim Berg and Norm Reuss (1995) suggest a structure for return visits, using
the mnemonic EARS: elicit, amplify, reinforce, start again. “What has been better
for you since you were last here? How did you make that happen for yourself? Who
noticed? What difference did it make to them? What difference does that make to
you? What else?”
In follow-up meetings, amplifying becomes even more important than during the
first meeting. Amplifying acknowledges progress and helps clients gather momentum,
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turning small changes into bigger changes. The focus is not only on what they did
better, but on how that made a difference for others. That is, how have others such
as parents, friends, and/or teachers benefitted from a positive change in the client or
student? Ultimately, how did a positive change in others benefit the client or student?
Consider the beginning of a second solution-focused individual counseling meeting
as described in the “Dialogue Box.”
DIALOGUE BOX
COUNSELOR: (After summarizing the last meeting including
strengths, accomplishments, and goals). “What would you say you
have you done better since our last meeting?”
SAMANTHA: (After thinking for a few moments) “Hmm, well, I did
my work.”
COUNSELOR: (Counselor emphasizes fluctuations) “Would you say
you did less work, about the same amount of work, or more work
since last time?”
SAMANTHA: “A little bit more work.”
COUNSELOR: “Well that’s terrific Samantha, fantastic! I’m delighted
that you are doing more work (cheerleads). What would you say you
did exactly that would help explain that you were able to do more
work now than before?” (detailing)
SAMANTHA: “I wrote down the assignment in my planner. Oh!, and
I put an alarm on my phone to remind me.”
COUNSELOR: “Awesome. How did you know to do that?”
(mind mapping)
SAMANTHA: “I remembered that our teacher told us to do this,
but I never did it.”
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COUNSELOR: “How are you doing it even when you might not
feel like it (mine fielding)? What do you tell yourself that helps you
to remember to put it in your phone (including cognitions and
beliefs)? What have your parents noticed about you doing your
homework? What difference do you think that makes to them? How
is life better as a result?” (more amplifying with others).
REFOCUSING FROM EXTERNAL TO INTERNAL
Like other counseling models, the solution-focused brief counseling approach
empowers children and adolescents to take control of their lives. When explaining
exceptions or progress already made, sometimes they will provide explanations
that rely on others or on external factors. This can happen during a first, second, or
subsequent meeting. For example, Marianne was asked, “How do you explain that
you are doing better this week as compared to last week?” She answered, “I didn’t
get in as much trouble because I’m on new medication that helps me to stay calm.”
Over time, I figured out an effective way to move from external explanations to
internal, refocusing on the individual’s contribution to the solution:
•
Step 1: Acknowledge the external factor. “Marianne, your medication seems
to be helping.”
•
Step 2: Consider existing fluctuations. “What I know, however, is that even with
your medication, some days are still better than others. What that tells me is that
your medication explains some of your progress, but not all of your progress.”
•
Step 3: Focus on the client. “So, what would you say you are doing and thinking that would also help explain that you are doing better?”
INVOLVING ALL STAKEHOLDERS
Solution-focused brief counseling is a systemic approach designed to include all
stakeholders. Early on, in the mid-1990s, when I was experimenting with how SFBC
worked with children in a school setting, I stumbled onto a bit of a glitch. I was getting
referrals from both teachers and parents who were highly distraught and “hanging
on for dear life” because the child or adolescent was behaving so badly. I remember
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one parent in particular who was admitting through her tears that she no longer
knew what to do and was embarrassed to admit that she did not even like being in
the same room with her child. After working with the children, I was excited to see
very positive results and in just a short duration of time! But when I approached the
teacher or parent to share and celebrate, they minimized the progress. They would
say things such as, “You don’t know this child like I know this child; he’ll regress.”
They seemed to think that the child’s progress was an exception and they continued
to expect bad behavior. I was caught off guard and truly surprised because I was
expecting some relief, hope, and maybe a bit of gratitude.
Why would a teacher, or especially a parent who has been struggling with a child
over a long period of time, not be as excited as I was about how much progress the child
had made? My colleagues and I struggled to find plausible explanations and considered
several possibilities. First, could it be that the teacher or parent was uncomfortable with
change? Could it be that he or she knew how to deal with a misbehaving child, perhaps
getting accustomed to the situation, and did not want to adjust to a new way of interacting? Second, could it be they just simply did not believe that such positive change
over a brief period of time was robust and real? Perhaps they were thinking that true
change could only be accomplished with efforts over a period of time commensurate
with the existence of the problem? Third, and probably most plausible, could it be that
they were embarrassed? As we thought through the scenarios, it began making more
sense. If a teacher or parent had been trying to help a child change for the better over
months or years and could not accomplish this, and you, the counselor, could do it in
a matter of weeks, might they feel incompetent or a bit ashamed?
In response to this issue, I developed the following process to minimize these possibilities, while enhancing the systemic solution-focused brief counseling approach.
Here’s how it works:
Step 1: First, acknowledge and praise the work that the teacher or parent has already
done. In a way, this means stroking his or her ego or at least recognizing his or her
efforts and dedication to the child. This is a time for cheerleading. You might say,
“You have worked really hard with this child/student for a long time. I am amazed
at how you have hung in there. You really care about his/her future!”
Step 2: Minimize your potential impact and emphasize teamwork. Let them know,
“I’m not sure that there is anything I can do that you have not already done. Perhaps
together we might be able to make a small change for the better.”
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Step 3: This next step is what I call issuing a BOLO or be on the lookout. Ask them,
“Please be my eyes and ears in the classroom or at home. If you see any sign or
exception that the child is more on track, doing the things we hope for, please let me
know. In fact, when I see you again, I will ask you what you noticed that might be a
sign that what we are doing is working.” The impact of this step is that we now have
teachers, parents, and perhaps other stakeholders involved in the intervention and
looking for signs of progress. What we know from this model is that you get more
of what you look for, and what we have observed is that when teachers and parents
look for signs of progress, they are more likely to find them. My colleagues and I also
discovered that, in turn, students notice adults giving them more attention when
they are better behaved, making responsible decisions, or achieving. Consequently,
even before the next solution-focused session, you may see progress just because
everyone is “on the lookout.”
Step 4: When progress is detected, conduct a solution-focused interview with each
person. Ask the teacher and parent, “What do you think you did in the classroom
or at home that would help explain how this child is improving? How did you do
that, even though it was sometimes frustrating or difficult?” “How is your life better
because he/she is more on track?” Then, conduct a follow-up EARS meeting with
the child—detail, mind map, mine field, cheerlead, amplify, and scale.
With these four steps, everyone is involved and gets credit, and they also feel
empowered and encouraged about the future. Another way to include all stakeholders is to collaborate with others who do solution-focused psychoeducation. School
counselors might collaborate with teachers, clinical mental health counselors, and/
or psychologists to deliver solution-focused classroom lessons, as described in the
“Add This to Your Toolbox” sidebar.
ADD THIS TO YOUR TOOLBOX
One of my favorite solution-focused activities involves doing classroom lessons with elementary school students after the first few weeks of the new
school year. I let them know that I am about to go over to the second-grade
class to help them succeed and I need their help. I say, “Because you are
in the third grade, I know that you did some things that helped you to be
successful last year.” I ask them, “What would you tell the second graders
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about what you did that helped you succeed? What have you seen others
do that makes them do a good job?” (Write these on the board). Then, take
the group through some mind mapping and mine fielding by asking, “How
did you make those things happen for yourself? How did you do it even
though it was not easy sometimes?” Toward the end of the first lesson, you
can begin to do some solution-focused scaling.
To prepare for the next class session, ask students to rate, on a scale
from 1–10, how successful they think they are in class. Next, have students
list behaviors that would help them increase the number on the scale. Also,
explain that everyone will get the name of a classmate that they will “spy”
on during the week, noting what this classmate does that helps him or her
be successful in class (such as asking more questions). During the second
meeting, students guess who spied on them and then they report their
observations. If a spy has nothing to report, you can turn to the large group
to see what someone else may have observed.
SOLUTION-FOCUSED PARENT CONFERENCES
Metcalf (2001) suggests that “instead of viewing a parent conference as a reporting
session for what is not working in school, teachers can construct an opportunity to
discuss what is working with the student” (p. 18). This is especially important given that
parenting a child with problems can be a stressful experience that can lead to various
defensive reactions, which interfere with finding solutions to the challenge at hand.
And, when interventions with youth are not successful, it is easy to point fingers of
blame. This may be one reason why some professionals see parents as uninvolved and
why some parents feel unsupported by school personnel (O’Sullivan, & Russell, 2006).
Thus, it is important to approach parent-teacher conferences in a way that leverages
the strengths, resources, and opportunities of all parties involved in a way that moves
the process forward and maximizes a student’s achievement potential. Applying the
solution-focused brief counseling approach to parent-teacher conferences seems to be a
natural choice given that all members of the conference must be empowered to do their
part, as a team, toward a particular mission—to help the student achieve and succeed.
In a different publication I (Sabella, 2014), wrote that in addition to avoiding the
“blame game,” another advantage of implementing solution-focused parent-teacher
conferencing (SFPTC) is that the approach includes concrete techniques and a relatively
clear road map during a potentially complicated process. This is important because I
have noticed that for some school counselors and school counseling graduate interns,
leading parent-teacher conferences (or even larger meetings) can be daunting. Some
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school counselors seem to have significant trouble managing the number of people
in the meeting, staying clear on each person’s respective role and responsibilities, and
making sure that the focus of the meeting stays on discussions and decisions that will
ultimately advance the student’s academic, personal, social, and career development.
The solution-focused model can provide school counselors with protocol for keeping
the meeting relevant and making sure that each participant focuses only (or at least
mostly) on his or her respective parts of the solution. Finally, the SFPTC model helps
ensure that the meeting stays upbeat, is productive, and leads to greater rapport among
all the stakeholders. In both the solution approach to parent-teacher conferences and
consultation with teachers and parents, either in school or mental health settings, the
goal is to provide support, planning, and coaching to help them better manage their
students and children. Read about a middle school counselor’s experience with SFBC
in the “Voices From the Field—Professional” sidebar.
VOICES FROM THE FIELD—PROFESSIONAL
In providing counseling and consultation services in an urban middle school with
ethnically and socioeconomically diverse populations, I find it imperative that
all school stakeholders work together to maximize the social, emotional, and
academic growth of our students. From creating academic plans and behavior
support plans, to addressing serious problems such as homelessness, incarcerated parents, or substance abuse, stakeholders often need to work together in
committees to find solutions to current problems and obstacles. Solution-focused
brief counseling (SFBC) meets our school’s needs, and stakeholders and students
can practice the SFBC principles and techniques as part of the decision-making
process related to students’ academic or social-emotional development. Being solution focused helps us to effectively address more long-term challenges, form strategies, and come up with [a] comprehensive plan. The positive and
forward-action framework of SFBC empowers students and stakeholders to take
charge of circumstances, improve them, and celebrate successful outcomes.
—Kathy, middle school counselor
THE PMS APPROACH TO SFBC
Throughout the time I have been practicing and contributing to the development of
the SFBC model, I’ve noticed that children and adolescents (and especially parents)
often do not want to respond, at least initially, to solution-focused questions. I have
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also found this to be true when conducting SFBC training with counselors and others
who are not readily willing to give up their problem-centered focus. In these cases,
I recommend beginning with a problem-centered focus and eventually working
toward being solution focused. I call this the PMS approach, which includes three
steps: explore problems, focus on motivations, and then finally focus on solutions
or scaling. Here’s how it works:
First, while exploring problems, keep your solution-focused ears tuned to exceptions,
efforts, strengths, resources, and potential goals. Next, ask, “How will your life be
different when these problems finally become resolved?” The answer to this question
typically has the client or stakeholder begin the process of brainstorming goals. This
can be a turning point toward solutions. Finally, begin the process of solution-focused
counseling, and perhaps starting with scaling. Read about how SFBC helped an 11th
grader deal with his father’s death in the “Voices From the Field—Adolescent” sidebar.
VOICES FROM THE FIELD—ADOLESCENT
I want to thank you for helping me so much since my dad died. I felt so lost and
depressed that I didn’t think I could on. You gave me hope and inspired me to
think about how he would have wanted me to carry on. You showed me how to
picture myself living the life he would have wanted for me, even if he’s no longer
here. Some days are still really hard, but you helped me stay focused on the times
when things were better, especially being with my friends and family doing fun
things. You taught me to keep asking myself, “What will I be doing that would
make my dad proud of me right now?” That has been so helpful. I really appreciate how you listened to me and gently helped me keep working hard even when I
didn’t feel like it. I know that this is my new normal, and I’ll keep living my miracle
no matter what.
—Marcel, 11th grader
CLASSROOM AND SMALL GROUP APPLICATIONS
According to Daki and Savage (2010), solution-focused brief counseling techniques
can “be applied in a variety of settings, such as individual and group counseling
with students, teacher and parent guidance meetings, and classroom management”
(p. 311). SFBC is becoming increasingly popular as a classroom management practice, and school counselors can use SFBC approaches to assist teachers in resolving
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classroom issues such as with students who are not getting along or students who
are not taking responsibility for their behaviors (Sklare, 2014).
Sklare (2014) outlines a five-classroom meeting progression that takes place over
about a two-week timeframe. Students are encouraged to identify the problems as well
as what is going well in the classroom. They may be asked the miracle question with
regard to how things could get better in the classroom and be asked to use scaling
to discuss the potential for improvement in the class as well as their commitment
to working toward improvement. Through this process, students work with teachers (and the school counselor, if involved) to continue to focus on behaviors that
improve the classroom environment for all. They are encouraged to intentionally
think about making the class experience better.
Solution-focused brief counseling concepts are also applicable in group settings.
Much like in family counseling, members in SFBC groups provide feedback to each
other based on their “observed interactions in and out of class” (Sklare, 2014, p. 158).
Issues such as behavior problems, social skills, and friendship issues (Sklare, 2014), as
well as specific learning issues (Daki & Savage, 2010) can be addressed in SFBC groups.
Daki and Savage (2010) provide an outline for a small group intervention with elementary-aged children struggling with reading difficulties. The outline highlights the
steps involved in the SFBC process. Each of the five sessions begins with a discussion
of “what’s better” (p. 326) with regard to their reading since last session, focusing
on members’ strengths. Following that discussion, members identify exceptions to
their reading problems (When is reading not challenging for you?). Beginning in
session two, members are introduced to the miracle question (If you woke up in
the morning and your reading difficulties were gone, how would we know?). The
miracle question then becomes a technique used in sessions three through five. In
general, the session plans are as follows:
•
Transitional session: Members draw their quality world.
•
Session 1: “What’s better?”—identify exceptions; discuss coping resources;
answer scaling questions about reading enjoyment; assign homework (reading
strategy they will try).
•
Session 2: “What’s better?”—discuss exceptions; ask miracle question; answer
scaling question about reading skills; assign homework.
•
Session 3: “What’s better?”—discuss exceptions; revisit miracle question; members participate in a creative reading exercise where they have the opportunity
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to use skills more effectively in an engaged environment; discuss strategies;
assign homework.
•
Session 4: “What’s better?”—discuss exceptions; discuss strategies attempted;
members complete creative exercise identifying people who help them read
(“Helping Hand” exercise) (Hobday & Ollier, 2005); give compliments;
assign homework.
•
Session 5: “What’s better?”—discuss exceptions; ask the miracle question;
discuss reading strategies as a group; record them on a large piece of paper.
TAKE-AWAYS FROM CHAPTER 5
As I conclude this chapter, I would like to refer to the brief vignette at the beginning
of the chapter and share what Mr. Callahan learned from working with his small
group of students, as well as a technique he used that I think was effective. A colleague
with whom he was consulting suggested that the students were grieving, but that
after a sufficient amount of time focusing on the grief, it might be more beneficial
for students to identify strengths to cope with the reality of their situations. From
a solution-focused perspective, Mr. Callahan learned to change his questions and
group activities to help the members focus more on how they are “making it” from
day to day, starting with solution-focused scaling. When he did this, he noticed
that the group began “turning the corner” and started feeling more encouraged and
inspired. I think this was an effective approach and his emphasis on helping group
members adjust to the many changes in their lives was very good.
After reading this chapter, you now should be more knowledgeable about these
key points:
•
The rationale for using SFBC with children, adolescents, and adult stakeholders
•
The basic principles and practices of SFBC
•
How to use the EARS model to facilitate second and subsequent SFBC meetings
•
Specific solutioning techniques applicable for young clients;
•
Examples of SFBC interventions
•
Small group and classroom applications, and applications with parents and
teachers
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HELPFUL WEBSITES
Solution Focused Brief Therapy Association (SFBTA). Provides professional
development, resources, tools, training, scholarships, research, and more
www.sfbta.org/
Unstuck. A website (and app) that uses the SFBC principles to help people
get unstuck
www.unstuck.com
Character Strengths, Character Building Experts: VIA Character. The VIA
Survey is a psychometrically validated personality test that measures an
individual’s character strengths
www.viacharacter.org/www/
Solution-Focused Approach (Online tutorial)
https://sites.google.com/site/solutionfocusedapproach/home
PRACTICAL RESOURCES
Solution-focused practice: An NSPCC toolkit for working with children and
young people.www.nspcc.org.uk/globalassets/documents/publications/
solution-focused-practice-toolkit.pdf
Solution-focused counseling resources on Pinterest
http://bit.ly/sfbc-pinterest
Solution-focused therapy resources and worksheets from psychology tools
https://psychologytools.com/solution-focused.html
Solution-focused brief counseling “cheat sheets,” training packet, and more.
http://schoolcounselor.com/professional-development/handouts/
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Kim, J. S., & Franklin, C. (2009). Solution-focused brief therapy in schools: A review of the
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Metcalf, L. (2001). The parent conference: An opportunity for requesting parental collaboration.
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Counselling Psychology Review, 26(3), 45–55.
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CHAPTER 6
Reality Therapy
Robert E. Wubbolding
LEARNING OBJECTIVES
1.
To identify five human motivators as defined in choice theory and how they
impact human behavior
2.
To describe the WDEP system of reality therapy and how it applies to children
and adolescents at various ages and developmental stages
3.
To discuss the significance of self-evaluation and how it applies to students
from diverse backgrounds
M
rs. Leonardo, a professional school counselor, currently functions as a
fifth-grade teacher in an elementary school. During her interactions with
the students, she uses the principles of reality therapy, which she believes
prevents most disciplinary problems. She describes behavior management in her
classroom as fluid and, for the most part, free of student unrest and interpersonal
conflict. When students chronically chose disruptive behavior, she meets with them
for a 5- or 10-minute conference. Rather than threatening them, she simply utilizes
the skills discussed in this chapter, helping them evaluate their own behavior and
make more responsible choices. One day after the class was dismissed and the students were exiting the classroom, she overheard the following conversation between
two fifth-grade boys, “Let me tell ya’ something. I used to be a problem for her, but
I decided not act out in her class like I had been doing before. The reason is that
if you keep horsing around, she calls you in for a conference. I thought she was
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going to yell at me the first time, call my parents, or send me to the principal. But
instead, we just talked and she asked me a lot of weird questions. They were really
hard to answer at first, and some of the questions were similar to what she asks us
in class. Let me tell you. It’s easier to behave in her class than to have to answer her
weird questions.”
The purpose of this chapter is to describe human motivation as well as to present
a practical theoretical approach for counselors to implement with children and adolescents. The approach is more successful if counselors share the information with
others so that all stakeholders can work as a team, using similar skills and thereby
improving the quality of the environment in school, at home, in the neighborhood,
or in other settings such as group homes.
CHOICE THEORY/REALITY THERAPY:
A UNIVERSAL SYSTEM
In countries throughout the world, counselors use reality therapy in their work
with children, adolescents, and adults. They apply it to individuals, groups, and
systems as they provide counseling and consultation services to clients from many
ethnic groups as diverse as Asians, South Africans, Middle Easterners, as well as
those from Western cultures (Wubbolding, 2017). Founder William Glasser, MD,
published his ground-breaking book Reality Therapy in 1965 and began to present
public lectures in response to widespread interest expressed by professional individuals and institutions. Although he first developed reality therapy in a correctional
institution and in a mental hospital for long-term residents, the audiences attending
his presentations were usually counselors, social workers, educators, human services
personnel, and corrections workers.
Few psychiatrists showed an ongoing interest in these new ideas. Consequently, he
quickly changed the name of his system from “reality psychiatry” to reality therapy.
Because of the emphasis on personal responsibility and the central place of choice
in explaining human behavior, educators sought out Dr. Glasser for more in-depth
training. As a result, Glasser and others developed the Schools Without Failure program in 1968. Subsequently, new and creative applications included additional skills
for teachers and systemic applications on a school-wide basis (Glasser, 1992, 1993).
Others, such as myself, have further extended Glasser’s ingenious ideas (Wubbolding,
2013), and we can now assert that the counseling profession finds choice theory and
the evidence-supported delivery system, reality therapy, to be significant, enduring,
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current, and most apropos to their work (Glasser, 2000; Wubbolding, 1988, 2011,
2017; Wubbolding & Brickell, 2015). For decades, school counselors have used it in
their work with students and in consultation with teachers and parents. From its
inception, mental health practitioners have applied reality therapy in private practice,
in group homes, and in correctional facilities and substance abuse treatment centers.
CHOICE THEORY—THE BASIS FOR REALITY THERAPY
Even though choice theory developed subsequent to reality therapy, it now serves as
an explanation of the effectiveness of reality therapy in counseling. Choice theory also
includes principles that can be taught to clients of virtually all ages. It is an internal
control system that explains human behavior as originating from within human
beings. Consequently, although cultural circumstances, early childhood experiences,
and other external factors impact individuals throughout every developmental
stage, the effective use of reality therapy focuses on what clients can control: their
own behavioral choices. A misconception about reality therapy is that it is based
on the belief that all actions and self-talk are freely chosen and that human beings
can simply select alternative behaviors. However, the principle of internal control
(i.e., that behavior springs from internal forces and that human beings have control
over much of their behavior) does not negate the impact of external influences on
human behaviors. And yet, even in a world of overwhelming external coercion,
some people find the ability to make choices. For example, the contribution of the
great existential psychiatrist, Viktor Frankl (1963) focused on the significance and
the possibility of human choice regardless of external circumstances. Even in the
diabolical world of a concentration camp, he still retained the power of choice,
which was to see purpose and meaning in his restricted world. This ability to make
a choice; that is, to perceive a purpose for enduring the cruelty around him, was an
amazing accomplishment.
HUMAN BEHAVIOR—THROUGH THE LENS
OF CHOICE THEORY
The principles of choice theory include the self-evident principle that the world
around us presents us with a wide range of possible choices and can limit our ability
to be free and independent. In essence, when counselors discuss personal responsibility, choices, and unavoidable consequences, they do not deny the existence of
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circumstances that can be severe and extremely challenging. When young clients
are dealing with these very negative situations, an empathic and compassionate
counselor can ask, “In spite of everything that holds you back, what are the choices
available today that would help you improve your life?” Glasser frequently stated
that although people may be victimized, they need not remain victims, especially
if help is offered.
The central place of choice in the theory underlying reality therapy means that
we all have at least some control over our behavior. A blind and rote application of
this principle may result in counselors treating clients’ misery and pain in a casual
and insensitive manner. A statement such as the following: “We won’t discuss your
frustrations or your past problems. They are in the past and there’s nothing you
can do about them,” indicates a shallow and inaccurate understanding of reality
therapy. Saying something like this has a negative impact on the therapeutic relationship, especially with young clients who may feel oppressed or rejected by the
majority culture.
Nevertheless, communicating to clients that they have more control currently
(i.e., more choices than they thought they had in the past) is empowering and compassionate. When clients feel hopeless and powerless, a skilled counselor not only
shows compassion and empathy for their current plight, but also demonstrates a
belief in their future success. Effective statements include, “In spite of the onslaught
you have suffered from your external environment, you have managed to survive.
Clearly, you have done what many people have not been able to do. I believe you
have managed your situation because you have made some very powerful choices.
Let’s talk about additional choices that are now available to you.”
EXPLORING TOTAL BEHAVIOR: FOUR COMPONENTS
It is important to know that behavior is divided into four levels or components: (1)
physiological behaviors, (2) emotions, (3) cognitions, and (4) actions. Physiological
behaviors are those over which we have some, but not complete, control. An example
of a physiological behavior is when a child goes to the nurse’s office complaining
of a headache. To understand physiological behavior, think of breathing. We can
hold our breath and do calming breathing exercises, but most of our breathing is
automatic. The second component is emotions—how we feel, the less controllable
component of total behavior. For example, when a preteen is not chosen for a part
in the school play, he or she may likely feel angry, hurt, and rejected. According to
the principles of reality therapy, we change our feelings by changing our actions.
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So, an adolescent could change sad feelings to happy feelings by reaching out
and helping a friend. The third component is cognitions, self-talk, or inner
conversations. Taking the previous example, when the adolescent is not chosen
for the play, he or she tells him- or herself that he or she wasn’t good enough.
However, his or her self-talk, the cognition component, can more easily change
because it is subject to more direct control than feelings and physiology. The
final component is actions. Children who exercise, take drugs, dance, or break
their curfews are exhibiting actions. From a reality therapy perspective, altering actions results in a change in feelings and inner self-talk when clients take
hold of the suitcase of behavior and lift it by the handle. So, the adolescent who
sulks and ruminates about not getting a part in the play could instead choose
to engage in a game of basketball with his or her friends and thus impact the
other components. At first glance this principle appears to be overly simplistic.
And yet, changing actions can bring about the desired changes if clients continuously change their actions and sustain them. The jagged arrow to the right
of the suitcase of behavior (Figure 6.1) illustrates that behavior can be a choice
resulting in alterations of total behavior—the four components just described—if
the distinctions between them are understood.
Perceptual Filters
O
U
T
E
R
WANTS
2. Belonging
3. Power,
Inner Control
AVIOR
BEH
W
O
R
L
D
1. Survival,
SelfPreservation
Action
Thinking
Feelings
Physiology
4. Freedom
5. Fun
–
+
FIGURE 6.1 Choice theory chart: Motivational system.
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BEHAVIOR AS PURPOSEFUL: THE SCULPTOR
Similar to Adlerian theory, behavior is always purposeful. Robey, Wubbolding and
Malters, (2017) state, “The purpose of behavior is to satisfy at least one human need
and more often more than one, as well as specific desires” (p. 287). More specifically,
behavioral choices are human efforts designed to impact the world around us, to
shape it and mold it as a sculptor molds clay. Sculptors hope that the statue they
make matches their internal picture, thus satisfying their need for achievement or
accomplishment. In order to operationalize the theoretical principle that behavior
is purposeful and is designed to impact or change the world around us, effective
reality therapists ask clients of any age, “What was your purpose in doing … ?” Or,
they can ask a parent, “You said you continually yell at your teenager and criticize
her. What is your goal in communicating in this way with your daughter?” Or they
can ask a 12-year old, “What did you hope to accomplish by repeatedly choosing to
pick on your friends?” Inquiries such as these make the theoretical principle practical and illustrate how the agents of the behavior (the clients and parents) seek to
regulate, moderate, or even dominate other people.
A second purpose of behavior, one that I have added to choice theory, is to communicate or send a message to the world around us. For example, children and
adolescents readily ascertain if a teacher likes or dislikes them or whether he or she
enjoys the subject matter he or she is teaching or merely tolerates it. Notice the difference between a history teacher telling 10th grade students, “You need this subject
in order to graduate,” versus the more effective teacher who says “I hope you will
learn to love the characters we study in history. My job is to do everything I can to
make this course satisfying and enjoyable for you.” The first message is devoid of
any positive emotion, whereas the second message conveys the teacher’s enthusiasm
for the subject and even adds a comment indicating his or her own responsibility
for the learning process. The sidebar “Now Try This!” will give you some practical
strategies for delivering effective messages.
NOW TRY THIS!
Imagine you are asked to talk to a teenager’s belligerent parent of the same
ethnic group as you. The parent is infuriated about the treatment of his adolescent who he believes has been unjustly singled out for stealing from his
teacher. How would you talk to this parent?
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Try the following: Keep your voice soft and calm, but firm. Acknowledge his
emotions with neutral words such as, “upset.” Ask him, “What would you
like to have happen now?” Express that by working together you can find
a way to address the problem (i.e., the perceived unjust accusation). Do
not take sides in this dispute. Remain neutral. Spend some time thinking
about how you would walk this tightrope. Write down some statements
you could make. Explain that he can scream at you in your office but should
remain calm when talking to the school administration. Almost immediately,
screaming loses its appeal. At some point, ask him to evaluate a few choices
that might be effective in solving this problem.
In summary, behavior is not randomly generated. It is not without purpose, even
though it might appear haphazard and erratic to the observer. The counselor’s role
is to help young clients clarify their purposes and evaluate the appropriateness and
effectiveness of their specific purposes, as well as their overall general purpose in life.
The dialogues in this chapter illustrate how to do this. You are invited to consider
your own additions to the dialogues and to evaluate the counselor’s interventions
that illustrate the various components of reality therapy.
Sample Dialogue Based on Needs and Purposes
Luke Pennington, 15, has been acting out in school, both in and outside of class.
Luke appears to be heavily influenced by peers who have dropped out of school
and are on probation. He has come to school high on drugs and has been referred
to juvenile court services. He now has to see a probation officer twice a month. His
teachers are concerned with his failing grades, and the school authorities have asked
Luke’s parents to speak with the school counselor. A partial conversation between
Luke’s parents and the counselor is as follows:
COUNSELOR: “Hello Mr. and Mrs. Pennington. I’m Sheila, Luke’s school
counselor. It’s good to meet you face to face. I hope you’re comfortable in
my office. I’ve tried to make it a welcoming place where students, parents,
and even teachers can relax as we consult with each other. I want to let you
know that it’s the school’s policy that when we have conferences with parents,
we can share relevant information with the administrators and teachers on
a need-to-know basis. We are very careful about ensuring that the information shared is not used against the student. I’d also like to emphasize that
the purpose of this conversation is not to blame anyone or to put anyone
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down. The idea is to figure out what needs to happen so that Luke learns
what is being taught in his classes to improve his failing grades and also
his behavior. I hope you’re okay with that. We will certainly talk about such
things in more detail.”
“I have the signed release that you sent to me giving me permission to
talk to the principal, the probation officer, and anyone else I need to consult.
The assistant principal has shared information with me about Luke’s current
behaviors and I have consulted with his teachers to learn more about his
behavior and performance in his classes. In addition, I have spoken to Luke’s
probation officer by phone, and he and I have shared as much as I can without
violating confidentiality. I also have met with Luke several times. So now I’d
like to ask you what you see happening with Luke.”
MRS. PENNINGTON: “I’m glad you said that our purpose here is not to
blame anyone. When we received the phone call, we thought we were going
to be chastised for Luke’s behavior.”
COUNSELOR: “The last thing I want to do is to blame you parents. There are
so many influences that impact students, including Luke, such as outrageous
music, videos, friends, drugs and alcohol, and social media. I know that we
do our best here at school to warn students about the consequences of
misusing social media, using drugs or alcohol, or engaging in other negative
behaviors that will come back to haunt them some day. Although we try to
help them avoid things that might cause problems for them, ultimately we
can’t really control what they do. The fact that Luke is engaging in some
troublesome behaviors that could affect him in the future must be uncomfortable for you.”
MR. PENNINGTON: “It’s very distressing, and that’s putting it mildly. My
wife and I are aware of the growing trend of teenagers to disclose too much
personal information through social media or engage in risky behaviors.”
COUNSELOR: “Judging from your expressions, both of you must feel out
of control at the thought of serious negative consequences that Luke could
experience if he continues down the path he is on now.”
MRS. PENNINGTON: “That pretty much describes it. We don’t know what
to do.”
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COUNSELOR: “I believe that by working together we can figure out some
ways to deal with these issues. Please notice that I’m saying ‘deal with,’ not
‘solve.’ I think we can make things better, but in reality, there is no guarantee.”
MRS. PENNINGTON: “That sounds realistic to me.”
COUNSELOR: “I have a question for you. When Luke was younger, say 11
or 12 years old, did the three of you have a close relationship?”
MR. PENNINGTON: “We felt closer to him than we do now, that’s for sure.
And he seemed to feel okay about us. Then he became a teenager and got
involved with a bad crowd and some very shifty characters.”
MRS. PENNINGTON: “We feel trapped and are at a loss about what to do.”
Analysis of the Dialogue
The school counselor worked on establishing an alliance with the parents. This is
the opposite of “calling them on the carpet.” The counselor hypothesized that the
parents might blame external influences for Luke’s behavior. Rather than initially discussing the fact that Luke chooses his behavior, the counselor shows an appreciation
for what she believes the parents might be thinking, namely that Luke is influenced
by his external environment and even swayed by negative messages from his peers.
The parents felt comfortable with the empathy demonstrated by the counselor, as
evidenced by the fact that they expressed feeling trapped and powerless.
The Session Continues
COUNSELOR: “It sounds to me like Luke has all the power and you feel as
if you have very little power. Tell me this. When was the last time you did
something with Luke that you all really enjoyed?”
MR. & MRS. PENNINGTON: They look at each other with a vacant stare
and are silent.
COUNSELOR: “You seem to have trouble remembering anything.”
MR. PENNINGTON: “It has been a long time since we have done something
enjoyable together.”
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MRS. PENNINGTON: “A couple of years ago we all went on a vacation to
Disney World and went to several parks, such as Epcot, where he especially
enjoyed the Japanese Pavilion and also appreciated thinking of the world as
‘spaceship earth.’ He talked enthusiastically about the idea of space travel
and the earth whirling around the sun at 17,000 miles an hour. We all had
such a wonderful time.”
COUNSELOR: “Your faces lit up when you described this happy experience.
Would you like to recapture some of that connectedness you felt with him,
some of the fun and the laughter?”
MR. PENNINGTON: “If we could just have a minute of time like that, it
would be wonderful.”
COUNSELOR: “Perhaps this would be a good goal for you could think about.
Keep in mind, however, that your son is no longer a pre-teen, and it’s typical
for kids at this age to have a change in attitude toward their parents and
gradually distance themselves from them.”
MR. PENNINGTON: “We know he is becoming more independent, but do
you think this is possible to re-establish a friendly relationship with him?”
COUNSELOR: “Yes, I do. But let me explain in some detail what we have
been talking about. You described your own inner needs, and it is true that
as human beings we have a need for belonging, a need for inner control, a
need for freedom, and a need for fun. You described how you feel disconnected from Luke and that you feel a lack of power or control and aren’t sure
what to do about this. You said that you feel trapped, which isn’t something
you like to experience.”
MRS. PENNINGTON: “Right. So, what do we do?”
COUNSELOR: “This is the crucial question. I would like to help you identify
some choices that would satisfy the four needs that we just mentioned. I
believe this should help you get closer to Luke and help him make better
choices, which is the primary purpose of this conversation today. If you are
willing, I would like us to explore how you talk to Luke and see if it’s working
to your satisfaction. If it isn’t, together we can figure out another strategy
that might be more helpful. Keep in mind that I am not blaming you or
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criticizing you. But I do think that you, as well as Luke, will be able to make
better choices about how you talk to each other.”
MR. & MRS. PENNINGTON: “That sounds very encouraging. Where do
we go from here?”
Analysis of the Dialogue
Notice that the school counselor did not immediately attempt to solve the problem
or help the parents identify a quick fix. Rather, she inquired about a time when the
parents’ relationship with Luke was better than it is now. She saw the ultimate goal
as a better parent-child relationship as the result of mutual steps taken together.
Therefore, the first step in this uphill process will focus on helping the parents communicate more effectively with their son. Using the reality therapy procedures, the
counselor will directly instruct the parents on more effective ways to talk to Luke and
will indirectly facilitate this process. The counselor’s effort focuses on the parents’
need for love and belonging and how to feel a sense of inner control resulting from
their self-talk; “we can do something about this problem.” As a result, they will not
feel so trapped and disempowered.
In summary, the dialogues illustrate how counselors can help parents satisfy their
needs by functioning as a consultant as opposed to a therapist. They also illustrate
one of Glasser’s major principles, which is that most human problems are relational
in nature (Glasser, 2003).
BEHAVIOR AS PURPOSEFUL: THE MESSENGER
Behavior is clearly purposeful and is designed to impact the world around us to
satisfy our needs. And yet, behavior has a second and more specific goal, which is to
send a message—a signal to our environment (Wubbolding, 2017). This addition to
choice theory opens another dimension to use with clients of any age. Our actions
and accompanying self-talk, as well as our feelings, send a message that is either
clearly discernible by others or implied or veiled. For example, a teenager might sit
very rigid with arms tightly folded and tell the counselor, “Everything is fine with
me.” The message might be somewhat disguised intentionally or unintentionally.
I’m not suggesting that counselors use this as an occasion for blunt confrontation
or for hasty interpretation, because it is important to be empathic. Empathy and
compassion are part of the therapeutic alliance, which will be discussed later in
this chapter.
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In Luke’s case, the school counselor can help him identify the message he is sending
to the world around him through his acting-out behaviors. The fact that he does not
study, flunks classes, uses drugs, and communicates poorly with his parents sends a
signal to people in his environment. Oftentimes, this behavior is an attempt to say
to the world, “Leave me alone. I want to do whatever I please.” Later I will discuss
self-evaluation and identify interventions that counselors can use to help clients
evaluate the messages that they send to the world. These evaluations are applicable
to clients of any age or culture, and they fit with the philosophy underlying diversity
and cross-cultural counseling.
Counselors also help clients like Luke explore what they want from the world
around them, as well as how they see people, places, and things; that is, their perceptions. They can help clients identify what they perceive they have or don’t have
control over. For instance, some children and adolescents, such as Luke, perceive the
world around them as a hostile place that they have no control over and they resist
adult supervision, instruction, rules, and policies. As a result, school authorities and
their parents often treat them in a coercive manner, saying such things as “These
are the rules, and it’s your job to keep them.” “You need this course to graduate,
and if you don’t do well, you will need to repeat it.” Counselors who practice reality
therapy with young clients use questions such as the following:
•
What do you think about the purpose of rules at home or in school?
•
Are any of them useful or helpful to you or your friends?
•
Would you be interested in trying to make your classes more interesting instead
of merely getting the grade on your transcript?
•
What motivates you more—playing an instrument in a band (or playing a
sport) because your parents pressure you to do it or because it’s enjoyable to
do so?
The purpose of using these questions is to help young clients realize that internal
motivation, (i.e., satisfying specific wants and general needs) is more satisfying than
merely making choices for external rewards such as grades or awards.
Learn more about the interaction with Luke by referring to the “Dialogue Box”
sidebar.
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DIALOGUE BOX
Let’s continue the case of Luke in this sample dialogue.
COUNSELOR: “Luke, what is the purpose of your behavior? What
do you want to accomplish?”
LUKE: “I just want others to leave me alone.”
COUNSELOR: “Luke, the opposite is happening. People are getting on your back more and more. It seems to be that you have two
choices: you can go down the road leading to success and freedom
from people telling you what to do, or you could go down the road
of getting a lot of crap from adults who tell you every move to make.
Let’s call one road ‘Happiness Highway’ and the other road ‘Misery
Boulevard.’ Which one do you want?”
LUKE: “I don’t know. I suppose the road where I don’t get a lot of crap.”
COUNSELOR: “OK, so let’s make a plan that gets you down the
right road. The plan can be SAMIC (simple, attainable, measurable,
immediate, controlled by the planner).
PERCEPTUAL SYSTEM
As previously stated, the first purpose of behavior is to impact the world around us.
Here, we add another major component of choice theory, the input or the perception
resulting from behavior. Wittingly or unwittingly, human beings seek perceptions
or images of their environments just as artists maneuver their materials so that the
artwork matches their mental picture. We are all sculptors seeking to shape the world
around us to satisfy our wants and needs. Luke’s parents’ desired perception is that
their son will be a law-abiding, cooperative young man who is successful in school.
On the other hand, Luke’s desired perception is to be independent and free of restraint
from his parents, his probation officer, and the school. The counselor will ask each
party to examine whether the perceptions they are gathering are those they desire.
We all desire perceptions. At times, we even deny ourselves information to maintain perceptions. For example, we change television channels when a movie becomes
grotesquely violent or we avoid learning every detail about an autopsy. Some of us even
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deny ourselves information about the way restaurant kitchens function. These everyday
denials help maintain a certain peace of mind. Please note that I am not recommending
any of these choices. The examples merely illustrate the significance of perceptions.
The desire for perceptions also explains the reason young people use drugs and
alcohol: It makes it easier to socialize, which facilitates the perception of friendship
or relaxation. When adolescents desire the perception of escape from psychological
pain or desire the perception of feeling powerful, these perceptions often result in
the continued excessive and destructive use of alcohol, opioids, marijuana, and many
other addictive substances. Acquiring pleasant, satisfying perceptions constitutes
the goal and purpose of behavior.
PERCEPTUAL FILTERS
Information passes through three filters when it enters the human mind from the
outer world (Refer to Figure 6.1). The low level of perception is the first filter, in
which information is labeled without judgment. For instance, a chair receives no
value; it is simply a chair. The middle level of perception allows the mind to see a
relationship, such as the chair is for sitting. It is not a table or a sofa. It has a relationship to its function. As information filters through the upper level filter, it is
given a value—the chair is comfortable. In contrast, when someone sees an electric
chair in a penitentiary, they assign it a very negative value.
School counselors often encounter students who have an indifferent attitude toward
their classmates or classes (low-level filter). Or, they see the school as a place to learn
and see the relationship between education and classroom activities (middle-level
filter). When they label people, ideas, activities, and the school itself with a positive
or negative value, they utilize their upper-level filter.
SPECIFIC SOURCE OF MOTIVATION
I have described human motivation as the fulfillment of the need system, although
needs are general and not specific. I also explained that human beings desire perceptions. Most perceptions are precise, specific, and unique to the individual. The
question remains, what links perceptions and needs? And, what specifically triggers
choices and behaviors that are less obviously choices? In other words, is it sufficient
to say that behavior springs from needs and that perceptions are directly connected
with needs? The answer is no. The intermediating component of choice theory is
known as “the quality world,” which is our inner world of specific desires, wants,
preferences, goals, and strivings (refer to Figure 6.1). This is analogous to a mental
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picture album that contains specific wants, which are often described as pictures
because of their specificity. For example, we have a need for belonging, and we have
a picture of specific persons or even pets who satisfy that need. Satisfying belonging
and wants, or pictures, can be very subtle. Also, pictures can be blurred, such as
when a child is confused about whether someone is his or her friend. Group counseling sessions often focus on how to develop and maintain friendships. In choosing
relationships, culture and religion can become barriers, and these issues can also
be addressed in a group setting.
Another question that arises is how the quality world relates to school and mental
health counseling. The work of the counselor includes the difficult task of not only
becoming part of the clients’ quality worlds, but also those of school personnel,
parents, and even members of the community: a daunting task indeed for counselors in any setting. Consequently, counselors work hard to be seen as competent,
credible professionals who can help young clients solve their problems, improve
their relationships and their school performance, and resolve many other personal
issues. To provide satisfactory service to educators and parents, as well as to facilitate
a higher level of social justice in the community, counselors strive to become part of
the quality worlds of the entire range of educational and community stakeholders.
Read how a professional counselor establishes credibility with trauma victims by
using reality therapy techniques.
VOICES FROM THE FIELD—PROFESSIONAL
I use reality therapy in a mental health agency with clients who have suffered
trauma resulting in out-of-control feelings, thoughts, and even actions. I use the
components of total behavior as an assessment tool: physiology of the client
such as tone of voice, facial expression, etc. I attend to the emotional affect of
the client such as anger, fear, or resentment and ask, “What thoughts go through
your mind about the current situation?” and “What would put a smile on your
face today?” Clients gain a sense of inner control by using deep breathing exercises and therefore feel at least some immediate, although momentary, control.
This activity helps to address trauma that, in many ways, is equivalent to a lack of
control. Clients also reflect on the best action choices available to them. I believe
that using reality therapy in this way has significantly enhances the counseling I
provide for clients.
—Peg, counselor in a mental health agency
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USING REALITY THERAPY
Reality therapy originated in a mental hospital and a correctional institution where
Glasser worked as a young consulting psychiatrist. He observed that the most effective
counseling provided to these populations emphasized personal responsibility and
the implied ability of clients to change their behavior by making healthier choices.
The focus on choosing behavior evolved into choice theory. Reality therapy, the
delivery system, began as an early and simple formulation, “What are you doing?”
and “What is your plan?” with the accompanying emphasis on the present rather
than on the clients’ past experiences, as illustrated by an anecdote told by Glasser
while working in the mental hospital. According to Roy (2014), a female patient
had spent most of her counseling sessions with other psychiatrists discussing her
relationship with her grandfather who had been dead for many years. When Glasser
became her psychiatrist, he insisted that they discuss her present reality, stating, “I
deal with what’s going on right now” (p. 67).
THE THERAPEUTIC ALLIANCE
Fundamental to all counseling practice is the therapeutic alliance. “Regardless of the
presenting issue, the effective use of reality therapy includes a therapeutic alliance
as a foundation for assisting clients to improve their interpersonal relationships,”
(Wubbolding, 2014, p. 310). The therapeutic alliance consists of three elements: the
relationship between the counselor and the client, mutually agreed-on goals, and
mutually agreed-on strategies.
“Effective outcomes achieved through the use of reality therapy and its cornerstone
intervention of self-evaluation require a strong yet flexible foundation,” (Wubbolding,
2017, p. 29). Even from the inception of reality therapy, the therapeutic relationship
was central and was labeled involvement (Glasser, 1972). According to Glasser (1972),
“For reality therapy to work, the therapist or helper must become involved with the
person he is trying to help; the therapist, therefore, must be warm, personal, and
friendly” (p. 108).
Mutually agreed-on goals and strategies implies defining realistic wants or outcomes, as well as both general and specific plans for reaching the goals. The WDEP
system described next spells out the process in detail. In consulting with teachers,
the school counselor helps them work with students to at least attempt to establish mutually agreed-on goals and strategies. These are more easily established in
schools, such as when the classroom teacher makes a continuing effort to stay in a
professional relationship with students that is firm, fair, and friendly. In a similar
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manner, counselors can help clients identify specific behaviors designed to satisfy
their needs for belonging or connection with other people. Young clients can then
explore how these connections also satisfy their needs for inner control or accomplishment, freedom (the new behavior is a choice), and fun (the activity might be
enjoyable). Figure 6.2 illustrates these principles.
CYCLE OF COUNSELING, COACHING, MANAGING, SUPERVISING, & PARENTING
E
N
V
I
R
O
N
M
E
N
T
E
W
Explore Total Behavior: Direction “Doing”
(”Acting”) Aspect, Self-Talk, and Core Beliefs.
Explore Two-Fold Purpose of Behavior: to
impact the outer world and to communicate
a message to it.
C. Get a Commitment (5 levels)
B. Share wants to perceptions
A. Explore wants, needs, & perceptions
BUILD RELATIONSHIPS
A. Structure the relationship
B. Use “attending behaviors” and reflective listening
C. AB-CDE
D. Suspend Judgment
E. Do the Unexpected Paradoxical Techniques
F. Use Humor
G. Establish Boundaries: Rules & Policies & Standards
H. Share Yourself & Adapt to Own Personality
I. Listen for Metaphors and Use Stories
J. Listen for Change Talk and Inner Control Talk
K. Listen for Themes
ESPECIALLY
L. Summarize and Focus
M. Allow or Impose Consequences
FOR
N. Allow Silence
PARENTS
O. Show Empathy
P. Be Ethical. Know standard care/relevant laws
Q. Create Anticipation
R. Practice Lead Management
4 A C T
S. Discuss Quality
T. Increase Choices
U. Discuss problems in past tense and
solutions in present or future tense
V. Withdraw from volatile situations if helpful
W. Talk about non-problem areas-redirect
X. Connect with the person’s thinking & feeling
Y. Invite solutions
Za. Use broken record technique
Zb. Use affirming language
Zc. Use questions and explorations
P
Make “SAMIC” Plans
P
(2 Types)
EPTION
RC
CURRENT
REALITY
PE
D
SELF-EVALUATION
(8 Types)
direct and Indirect
OF
P
R
O
C
E
D
U
R
E
S
TRUST
HOPE
R
F
F
E
F
L
A T
T
T O
O
I N
X
O I
I
N C
N
S
S
H S
I
P
S
Follow Up,
Consultation,
Continuing
Education
R
E
L
A
T
I
O
N
S
H
I
P
S
A. Argue, Attack, Accuse
B. Boss, Manage, Blame, Belittle
C. Criticize, Coerce, Condemn
D. Demean, Demand
E. Encourage Excuses
F. Instill Fear, Find Fault
G. Give Up Easily, Take for Granted
H. Hold Grudges
Ericksonian underlying and compatible principles (requires
explanation).
1. Solution can seem to be “unrelated” to the problem
2. The problem is the solution
3. “Seed” major interventions
P
R
O
C
E
D
U
R
E
S
E
N
V
I
R
O
N
M
E
N
T
FIGURE 6.2 Cycle of counseling.
THE WDEP SYSTEM OF REALITY THERAPY
For the sake of simplicity, I have formulated reality therapy as a WDEP system for
the purpose of providing a learning and teaching tool (Wubbolding, 2000, 2017),
and it is very applicable in counseling as well as in consultation in school and mental
health settings. In this acronym, the W stands for wants, perceptions, and the quality
world. The D stands for actions, feelings, and self-talk (cognitions), the E stands for
self-evaluation, and the P stands for plan.
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THE W: EXPLORING THE QUALITY WORLD AND
­PERCEPTIONS
Experience has shown that many children and adolescents have unclear pictures of
what they want from school, peers, teachers, parents, and from the world around them.
Oftentimes, much of their world of wants focuses on their desire to engage in social
media by texting, using Facebook, playing video games, or watching movies. Counselors can help young clients define, for instance, what they want from their school
experience, their peers, their parents, and what they hope the outcome of counseling
will be. This exploration of wants is expressed in many different ways, as illustrated
in the following dialogue with Ling, a 13-year-old Chinese female. Ling is an average
student, and this routine semi-annual interview was initiated by the school counselor.
Exploring Wants
COUNSELOR: “Hello Ling. I’ve been wanting to talk with you about how
things are going for you here at school. Are you comfortable in my office?”
LING: “Yes, it’s fine.”
COUNSELOR: “Tell me a little bit about how you feel about school.”
LING: “Sometimes it’s OK, but sometimes it isn’t.”
COUNSELOR: “Tell me, Ling, what would you like to have happen as a result
of our conversation?”
LING: “I’m not sure. I guess I’d really like to know how to make friends.”
COUNSELOR: “Ling, we can get more specific about that later. But right now,
I’d like to ask you about what you are seeking from your classes or from your
friends. Let’s start with what you’re hoping to get from one of your classes. I
believe you are taking a social studies class called Themes of Freedom, which
is about the history of people seeking freedom from tyranny. Is that right?”
LING: “Yes. I would like to learn about how various tribes and nations achieved
what the teacher has called self-government.”
COUNSELOR: “I am also wondering how you can use this class as a way
to develop a few friendships. Is there somebody in the class that you have
already connected with?”
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Analysis of the Dialogue
In this brief dialogue, the counselor attempts to soften the question, “What do you
want from your classes?” He asks the client what she is seeking. For many clients,
this question sounds less intrusive and not as harsh as the seemingly blunt inquiry
“What do you want?” When I first discovered this alternative way of using reality
therapy I believed that the questions sounded almost identical. And yet, using such
words as “seeking,” “striving for,” and similar phrases seem to be more culturally
acceptable and therefore more likely to elicit information useful for follow-up counseling. While this awareness can be helpful, counselors do not need to be overly
concerned about saying the right thing because clients from many countries and
cultures adapt American behaviors more rapidly than in previous generations.
Exploring Satisfied and Unsatisfied Wants
Part of discussions focusing on children and adolescents’ quality worlds includes
identifying what they believe are deficits in their world of wants. A useful metaphor is an “out-of-balance scale” (Figure 6.1). Because human beings rarely get
everything they want, a discrepancy exists between desires and satisfactions. For
example, a first grader might want to stay home with her mother, but instead has
to sit in the classroom. For a young child, the out-of-balance scale is painful, and
the only behavior available to balance the scale is sometimes panicking, crying,
getting angry, or feeling distressed. An older minority pre-teen or teenager might
feel ostracized, ignored, or mistreated as a result of an out-of-balance scale and lack
available choices to balance the inner scale.
Jamal’s Satisfied and Unsatisfied Wants
Jamal is an 11-year-old male of above-average intelligence who transferred from
another school three months ago. The school counselor and his parents have referred
Jamal to a mental health clinic for mild but chronic acting-out behaviors and declining grades.
COUNSELOR: “Jamal, your school counselor and your parents want me to
work with you. What do you think they had in mind when they sent you to
talk to me?”
JAMAL: “You don’t understand me at all. You’re White. What do you know
about my life?”
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COUNSELOR: “You’re right, Jamal, I know very little about what it means
to be African American. But could you tell me what’s going on now that’s
so upsetting to you?”
JAMAL: “The teachers don’t like me. They told me I’m lazy and they give
me bad grades.”
COUNSELOR: “And this bothers you?”
JAMAL: “I don’t care what they think of me.”
COUNSELOR: “I understand you’ve also had some trouble with the other
kids in your neighborhood.”
JAMAL: “Yeah, we get into a lot of fights.”
COUNSELOR: “Jamal, there’s a lot I don’t know about your world. But I believe
I can help you feel better about school and improve your relationship with
the kids in the neighborhood and with your parents.”
JAMAL: “How and why?”
COUNSELOR: “Let me answer why first. I see you as a good student and
you are worth whatever effort I can make to help you succeed in this school.
I know you’re in trouble now at home, but I believe it is only temporary.”
JAMAL: “You don’t even know me.”
COUNSELOR: “I know you a little in the few minutes we have talked here
today. Let me explain what I see happening. It’s as though you have a kind
of mental scale inside your head that is out of balance. It’s something that
all human beings have. So, when you want something and you’re not getting
it, it seems like that’s when you get upset. It’s not good or bad; it’s just out
of balance. It’s what people of any nationality do when they don’t have what
they want—they get upset.”
JAMAL: “In other words, I’m the same as everybody else.”
COUNSELOR: “Yes and no. You have the same workings in your mind. But
the out-of-balance scale is much worse for you because you feel looked down
on by people, such as your teachers, who don’t even know you. I would like
us to set a goal: that you will feel better about being an African American
student in a mostly Caucasian school. I think if that would happen, all the
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other aggravations would become more manageable and less painful. In
other words, your good old mental scale would be back in balance.”
Analysis of the Dialogue
The interaction with Jamal illustrates that the counselor doesn’t need to know everything about the client to be of assistance. Also, the counselor does not apologize for
racial barriers. This brief dialogue also portrays the usefulness of teaching clients
about one component of choice theory: the out-of-balance scale. The counselor
avoids the conventional request that Jamal tell him about his world, and although
this would be a legitimate discussion, the counselor wants to provide immediate help
to Jamal based on an understanding of choice theory. This will be further explained
under the discussion of perception.
Exploring Perceptions
Many clients perceive themselves as victims and their locus of control as external.
The skilled user of reality therapy facilitates his or her journey from “victimize to
victim wise.” Reality therapy does not deny the self-evident fact that people are
victimized, but counselors can apply the principles of this approach to help children
and adolescents feel less like victims by helping them realize that while they do not
have total control over their lives, they have more choices than previously perceived.
This principle occupies a central place in the application of reality therapy and is the
opposite of “blaming the victim,” as illustrated in the following dialogue with Jamal:
JAMAL: “I hate everything about school.”
COUNSELOR: “OK. Tell me what you hate the most.”
JAMAL: “I hate Mrs. Z. She’s the worst.”
COUNSELOR: “I’ll bet you’d like to call her a few names. You don’t have to
tell me what they are, but I imagine they’re pretty negative.”
JAMAL: “Yeah, she puts me down, picks on me, and when she looks at me
she’s got fire in her eyes.”
COUNSELOR: “So, she’s the person you dislike the most. What about school
do you dislike the least or almost like?”
JAMAL: “History class. It’s not too bad.”
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COUNSELOR: “Talk a little bit about what you like about it.”
JAMAL: “Mr. L. makes the class interesting. He tells stories about the people
who made things happen and some of the stories are funny.”
COUNSELOR: “What would be an example of a funny story that he tells?”
JAMAL: “He said that Napoleon kept his hand inside his coat because he
kept his wallet there and his back pocket had a hole in it!” (Jamal smiles
broadly as he recounts the teacher’s story.)
COUNSELOR: “I noticed you smiling as you told the story. Would you be
interested in having a few more smiles at school?”
JAMAL: “Yes, of course.”
COUNSELOR: “For you to make that effort, in your opinion, what percentage
of all the misery that you feel in class do you believe is caused by the school
and what percentage are you causing? The answer is just a guess.”
JAMAL: “I guess I’m causing about 30% and the school 70%.”
COUNSELOR: “Wow! I’m surprised! You’ll take responsibility for about a
third! And you also said that there are some things about the school that
you like, such as history class and Mr. L. Let’s talk about the 30%. What do
you think you have the most control over? What’s something you could do
differently that would make your day better?”
JAMAL: “Well, guess I should do something different in Mrs. Z’s science
class.”
COUNSELOR: “May I make a suggestion?”
JAMAL: “Sure.”
COUNSELOR: “Show up on time for 5 straight days. And I have another
suggestion. I know she asks students to make reports. Can I suggest a topic
for a report?”
JAMAL: “Yes, I wish you would.”
COUNSELOR: “How about asking the teacher if you can make a report about
Charles Drew. He was a physician, a surgeon, and a medical researcher who
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died in 1950. If you Google him, you can find pictures and information about
what he accomplished.”
JAMAL: “So you’re saying that I should take some action myself.”
COUNSELOR: “What would it hurt? In fact, do you think it could help?”
JAMAL: “I think it would help.”
Analysis of the Dialogue
Jamal believes his troubles are caused by outside forces, so rather than argue with
him, the counselor accepts his perception—his viewpoint about the quantity and
source of his frustration. He then tells Jamal that he will help him build on his sense
of inner control, the 30%. He does not stress Jamal’s self-imposed misery, and he
has no intention of trapping Jamal into taking responsibility. Rather, the counselor
helps Jamal choose to formulate a plan that might make his school experience more
enjoyable. The counselor gradually guides Jamal from an all-pervasive sense of
powerlessness and victimhood to the perception that he can take responsibility to
improve his life if he chooses to do so.
THE D: FOCUSING ON ACTIONS
It seems that most reality therapists in any setting focus on client actions because
the handle of the suitcase of behavior is attached to the action level, symbolizing
that human beings have the most direct control over actions. When children and
adolescents change their actions, the other three components follow. This principle
does not diminish the ethical principle that the counselor always functions within
the boundaries of his or her limitations. For example, counselors refer clients with
physical infirmities or other conditions, such as mental disabilities or learning limitations, to specialists who focus on these specific problems and issues, which are
beyond the counselor’s skill level. Nevertheless, even after such referrals take place,
counselors can continue to work with these clients by discussing their actions and
helping them make positive plans to change. Consequently, children often embark
on a rapid journey from feeling negative feelings such as loneliness and negative
self-talk, such as “I can’t,” to positive feelings of friendship and “I can.” This change
occurs by changing actions.
Remember that the D consists not only of actions, but also of feelings and internal
self-talk or cognition. In cognitive behavioral theory, self-verbalizations are the sources
of mental disturbance (Neukrug, 2015). Albert Ellis, the founder of rational emotive
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behavioral therapy, often quoted the stoic philosopher Epictetus, “Men are disturbed
not by things but the view which they take of them,” (Neukrug, 2015, p. 189). Alfred
Adler, who developed individual psychology, was quoted as saying, “I am convinced
that a person’s behavior (actions) springs from his ideas,” (Neukrug, 2015, p. 190).
In working with clients on the D, counselors help them identify what they are
currently doing (actions, cognitions, feelings) in an attempt to get what they want.
A counselor might ask, “If I were to observe you over the next few days, what would
I see you doing, thinking, or feeling? Would I see you being angry, telling yourself
this is an impossible situation, or refusing to connect with the people who can help
you figure this out?”
THE E: SELF-EVALUATION
In the original formulation of reality therapy, Glasser (1972) described the necessity
of asking clients, “Is what you’re doing helping?” This simple question represents
the major contribution of reality therapy to the counseling profession because no
other theory or approach places as much emphasis on this long-standing reality
therapy question. And yet, this question is not merely a single inquiry used by reality
therapists. Rather, it is a cluster of ideas symbolized by the question. Thus, it can
be used as it stands, but the artistic use of reality therapy includes a wide variety of
possible interventions, as depicted in Figure 6.2. I (Wubbolding, 2000, 2011, 2017)
have expanded this simple but profound question with the following examples that
promote self-evaluation:
•
Is your overall life direction helping or hurting you? Describe whether you
are headed in the direction that is advantageous or disadvantageous to you.
Where are your choices leading you?
•
When you chose to do … did it help you or hurt you? Tell me how that specific
action benefited anyone or hurt anyone else. Describe how your current actions
are helping you or preventing you from getting what you want.
•
Tell me about the impact of your actions on your family, your friends, and
your community, etc. (This form of self-evaluation is especially useful in cultures or sub-cultures where clients are less individualistic and more mindful
of family relationships often characterized by respect and esteem for elders).
•
Is what you’re doing congruent with rules, policies, laws, and family
expectations?
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•
Describe your thoughts about the acceptability of your actions. Are they in
line with the unwritten rules in our society?
•
Is what you want realistically attainable?
•
Describe how your wants are helpful or harmful to you and how they are
helpful or harmful to other people.
•
Is it true that you’re at the mercy of everyone else? Are you really a victim who
will always be a victim? Describe how everyone around you controls you. Can
they really control you?
•
If you continue to tell yourself, “I can’t,” will you ever be able to achieve your
goal? Describe some inner self-talk statements that would help you.
•
Describe whether your plan fulfills the characteristics of an effective plan. For
instance, if you say, “I’ll try,” will that get the job done?
Learn how to use self-evaluation with young clients by referring to the “Add This
to Your Toolbox” sidebar.
ADD THIS TO YOUR TOOLBOX
Self-evaluation is a building block in the structure of reality therapy. I suggest you end every counseling session by asking the client or the group of
clients, “What was useful to you in this session?” or, “What will you take
away from our conversation today?” Asking the question in this simple,
positive manner helps clients insert a practical, positive outcome into their
behavioral system: action, thinking, and feelings. This is especially useful
with clients who see the world as against them, who make negative judgments about their environment, or who lack positive self-esteem.
I cannot emphasize enough the significance of utilizing self-evaluation (E) in
counseling young clients and consulting with their parents, because they often believe
that if something is not working, do more of it. For example, in parent consultations,
I suggest asking parents if they argue, blame, or criticize their children. Almost
invariably they answer in the affirmative and even assert that if it is not working
they will still repeat the same ineffective action. Helping parents self-evaluate is an
essential pre-requisite to the formulation of a more effective plan. Often abandoning
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these toxic behaviors enhances the parent–child relationship, the dysfunction of
which can be a major contributor to young clients’ unhappiness.
Additionally, using drugs diminishes the skill of self-evaluation. Individuals who
abuse licit or illicit drugs are unable to evaluate their own behaviors and the behaviors of others. Rotgers (2012) describes how coping skills become deficient “as the
individual may be unable to cope with the problems associated with substance use
itself and increase their use in an effort to cope with increasingly frequent negative
emotions,” (p. 125). The user’s ability to evaluate the efficacy of choices becomes
compromised. Also important to note is that children raised in a substance-abusing family often experience inconsistencies in family relationships. For example, if
a child receives praise one day and punishment the next day for the same type of
behavior, he or she becomes increasingly less able to evaluate what helps and what
hurts because his or her cognition is filled with inconsistencies. Finally, relationships
crumble due to a lack of trust, lack of consistency, and lack of appreciation for each
other. Self-evaluation lies at the heart of a happy and integrated family life.
THE P: PLAN OF ACTION
The most easily remembered component of the WDEP system is the plan of action
because planning is central to many counseling theories and is a requirement
described in ethical codes. The ACA Code of Ethics (2014) states, “Counselors and
their clients work jointly in devising counseling plans that offer reasonable promise
of success and are consistent with the abilities, treatment, developmental level, and
circumstances of clients” (A.1.c.). In formulating treatment plans in reality therapy,
Fulkerson (2015) states that “instead of using the client diagnosis as the central
guiding mechanism in treatment planning, the reality therapist uses the five basic
needs as a diagnostic schema and a starting point in assessing client strengths, areas
of improvement, abilities, and preferences. By gathering this information, the reality therapist can more easily produce a treatment plan that is more individualized
and practical” (p. 5). “More specifically, the reality therapist helps clients identify
quality world pictures or wants that are satisfied, as well as pictures or wants that
are unsatisfied, vague, unclear, or in conflict with other quality world pictures”
(Wubbolding, Casstevens, and Fulkerson (2017, p. 473).
Ideally, each counseling session culminates in a plan characterized by the following
qualities: simple (uncomplicated), attainable (realistically achievable), measurable
(answers the question, “When will you implement the plan?”), immediate (as soon
as possible), controlled by the planner (not dependent on another person), consistent
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(repetitious; not a plan implemented only once), and committed to (hand shake,
follow-up report). It is unrealistic to expect every plan to contain all these characteristics; that would be the ideal. In reality, many plans are less than ideal.
REFLECTING THE WDEP SYSTEM
The dialogue in the following case illustrates the nuances of the WDEP system
previously described: W: quality world or world of wants, perceptions; D: clients’
actions, thoughts, and feelings; E : counselor’s efforts to help clients self-evaluate;
and P: culmination in a plan of action.
THE CASE OF SEAN
Sean is a 13-year-old self-referred Caucasian client. The counselor knows very little
about Sean or why he is seeking counseling. After helping him feel comfortable, the
counselor discusses informed consent and other ethical issues such as duty to warn.
COUNSELOR: “Sean, you wanted to see me. I’m wondering what’s on
your mind.”
SEAN: “After you came to the class for a class meeting and discussed what
it means to be an adolescent, I decided to talk to you about something.”
COUNSELOR: “You said you decided. I think it takes guts to make such a
decision. What is that ‘something’?”
SEAN: “You talked about friendship and how important it is to have friends.
I think there must be something wrong with me because I don’t have
any friends.”
COUNSELOR: “I admire you for being so willing to bring this up with me.
What would you like to take away with you from today’s session?”
SEAN: “I’d like you to tell me how to get friends.”
COUNSELOR: “I think I can help you with that. Let me ask you this. Did you
do anything yesterday that would help you get a friend?”
SEAN: “Nothing I can think of.”
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COUNSELOR: “Just summarize what you did at school, such as talking with
other students.”
SEAN: “Not much. I just went to class and then took the bus home.”
COUNSELOR: “So, not talking to other students didn’t help you get a friend.
Am I right about that?”
SEAN: “Right.”
COUNSELOR: “Sean, as you look around, do you know anyone who
has friends?”
SEAN: “Yes, it seems to me a lot of kids at school have friends.”
COUNSELOR: “What do you think they do to make friends that’s different
from what you do?”
SEAN: “Well, they hang out together, sit together in the cafeteria, text each
other, all kinds of stuff.”
COUNSELOR: “If you were to choose to reach out to someone, who would
it be?”
SEAN: “I think it would by Ben Harris.”
COUNSELOR: “So, he seems like a pretty good guy. Let’s put it this way,
Sean. If you don’t say anything to Ben today, will anything change for you?”
SEAN: “I guess not.”
COUNSELOR: “Are you willing to do something different today that would
be a first step toward having friends?”
SEAN: “Yes.”
COUNSELOR: “Let me put it another way. If you don’t do anything different,
is anything going to change?”
SEAN: “Probably not.”
COUNSELOR: “And you definitely want things to change. How hard are you
willing to work to gain a friend?”
SEAN: “I will work hard at it.”
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COUNSELOR: “Keep in mind what the coach said to the team at our assembly
this morning. He said that working hard in the beginning of the season results
in success toward the end of the season. In other words, it takes continued
practice even if at first you fail.”
SEAN: “I heard the coach say that.”
COUNSELOR: “So, what’s your plan for today? How will you approach Ben
and when?”
SEAN: “I don’t know.”
COUNSELOR: “Can I make a suggestion?”
SEAN: “OK.”
COUNSELOR: “How about asking Ben a simple question, like if you could
hang out together at lunch time today?”
SEAN: “I can ask. What if he says no?”
COUNSELOR:“I’d suggest you just say, ‘OK, maybe some other day.’ Even
if he is not interested, this will be a big success for you because you took a
major step toward your goal. Keep in mind a failure is always a step in the
right direction. A failure is simply a delayed success.”
SEAN: “Then I can always reach out to someone else.”
COUNSELOR: “Wow! You’ve got an idea we didn’t even mention. I think
you’re on the right track. Oh yes, one more thing. At the end of school before
you run out to the bus could you just come by my office and tell me how it
went? I always stand outside my office. Our conversation would take about
5 seconds.”
SEAN: “Sure, I’ll do that.”
COUNSELOR: “See you then. One more thing, what do you think was the
most important idea we discussed?”
SEAN: “That I need to do something different from what I’ve been doing.”
COUNSELOR: “I agree.”
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Analysis of the Dialogue
In this brief session, the counselor inquired about Sean’s wants, and, more specifically,
what he wants from the session. They discussed current actions, and the counselor
helped Sean make the self-evaluation that his current actions are not getting him
what he wants. After Sean examined his previous choices and said that they were
not working, he was impacted by this judgment and saw that he needed an alternative plan. The school counselor asked Sean to evaluate the counseling session by
asking him to define the most important point of the session. This illustrates that
the component of self-evaluation is more than self-evaluation. It can also take the
form of evaluating the counseling session.
As stated earlier in this chapter, the dialogues are intentionally brief and intended
to illustrate practical principles of choice theory and reality therapy. They intentionally omit things that are a part of most counseling sessions to focus on the essentials
of reality therapy.
Now that you have read some sample dialogues illustrating reality therapy principles, refer to the “Personal Reflection” sidebar to engage in some personal reflection.
PERSONAL REFLECTION
Now that you have read about reality therapy, it is time to critique it. To
help you reflect on reality therapy, I will use techniques derived from the
theory and practice:
•
What did you find most useful in the chapter?
•
Describe your reasons for rating the idea most useful.
•
How can you use the principle of self-evaluation in your personal life and
in your professional life?
•
Have you made or are you currently making choices that you now evaluate
as ineffective? Are you telling yourself in any way, “Even though my current
choice is not working, I will continue to do it”? Don’t feel embarrassed if
you make ineffective choices. Remember the words of John Adams, one
of the founders of the United States, “That’s human nature.” From the
point of view of choice theory, you can be more specific in explaining your
motivation. What needs are your choices designed to fulfill?
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REALITY THERAPY AND DIVERSITY
The question is, “Does choice theory explain the wide diversity of desires, behaviors,
and perceptions among the innumerable cultures existing on planet Earth? How does
choice theory account for the hopes and dreams of people from diverse cultures? Does
it explain the motivations of the Amish, Inuits, Sihks, Native Americans, African
Americans, and the thousands of other cultures that currently exist and have existed
throughout history?” The answer is that from the reality therapy point of view, all
human beings are motivated to satisfy their need for survival or self-preservation,
belonging and love, inner control, competence or power, freedom or independence,
and fun or enjoyment. Springing from these needs and from behaviors are specific
desires, hopes, goals, and dreams. Individuals insert these wants into their quality
worlds, their worlds of wants, or their mental picture albums. This inner world
of desires and strivings is circumscribed by individuals’ experience within their
cultures. More specifically, an adolescent raised in Japan experiences the Japanese
culture (or more accurately one of the Japanese cultures) and more than likely speaks
Japanese as a first language. Similarly, behaviors and their resulting perceptions
are bordered by cultural experiences that include traditions, taboos, relationships,
and opportunities.
A word of caution is necessary. Ethnic or national identification that limit cultural experiences is not absolute because many people incorporate a wide range
of experiences that might not be peculiar to one culture. Some people reflect their
cultures by communicating more indirectly than others. Furthermore, cultures
allow for a wide range of behaviors that overlap with other cultures. An effective
Caucasian counselor avoids stereotyping clients by not assuming that just because
a client is Chinese, for example, that he will excel in school and not be interested
in American sports. Similarly, it is ill-advised for a minority counselor to perceive
Caucasian students as “privileged.” A better use of reality therapy happens when
counselors explore with clients how they perceive themselves rather than relying on
labels given to them or by the expectations of society. In essence, counselors need to
be aware of what they are taught in their basic counseling course, which is to treat
clients as individuals, not as representatives of a cultural, religious, or ethnic group.
APPLICATIONS WITH PARENTS AND TEACHERS
Although there are many reality therapy principles that parents and teachers can
use, I wish to stress two major applications. Parents and teachers can enhance their
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communication with children, and therefore their relationships, by avoiding toxic
behaviors, especially arguing, belittling and blaming, as well as criticizing. The
replacement for these ineffective behaviors is to use the WDEP system, especially
asking children to evaluate their own behavior. When parents and teachers spend a
few minutes asking children what they want from the world around them, helping
them evaluate the effectiveness of their choices by asking (not telling them) “Is what
you’re doing helping you?” gradually results in a sense of internal control for both
the adult and the child. There are many spinoffs of this inquiry, and they need to
be adapted to specific situations. For example, asking children “What’s your plan
now?” can pay rich dividends that exceed the expectations of teachers and parents.
I routinely suggest to parents that when their children are upset that they calmly
ask them, “What do you want to have happen now?” or “What is your choice now?”
The WDEP approach focuses on the perceptions of both the adult and the child
about what they can control as opposed to external forces over which neither adult
nor child has control.
USING REALITY THERAPY IN GROUPS
Reality therapy expressed in the acronym WDEP is eminently applicable to group
counseling. Essential to its effectiveness is the counselor’s relationship with group
members. If group members see the counselor as someone who understands and
accepts them regardless of their problems or status, they are more willing to make
changes that satisfy their needs more effectively than they have in the past. In general, the following group formats are useful.
VOLUNTARY GROUPS
When students volunteer to participate in a group focusing on such topics as parental
divorce, grief, recent transitions such as moving or changing schools, incarcerated
parents, academic difficulties, career exploration, or other issues, the following
outline can be followed:
•
Help group participants define their goals for group counseling sessions.
Counselors ask children or adolescents who volunteer to participate in a group
to define what they want to gain, that is, to clarify their quality worlds regarding desired outcomes.
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•
Help group members describe their total behaviors. This includes discussions of
current actions, thoughts about the topic of the group, and feelings experienced
in the here and now or on a habitual basis. Because group members have more
direct control over action choices, the counselor focuses the discussion on actions.
•
Facilitate participants’ self-evaluation. With the help of the counselor, group
members describe the effectiveness of their choices by focusing on the question,
“Are my current actions helping or hurting me and what impact do they have
on the people around me?” Group participants can help each other evaluate
these behaviors.
•
Formulate plans for the future. These plans can be individualized or they can
apply to the entire group. A caution is that counselors facilitate planning, but
that does not include getting others to change their behaviors. Rather, plans
focus on each participant’s actions that they have control over.
INVOLUNTARY GROUPS
Counselors often form counseling groups based on specific client needs. In a school
setting, the administration could request that a specific type of group be offered to
address or a systemic problem such as diversity-related issues, bullying and harassment, academic failure, conduct problems, or other obstacles that detract from the
learning environment. In a mental health setting, counselors might form similar
types of groups based on what several clients are struggling with, such as eating
disorders, depression, anger management, or anxiety.
Suggested Format
The outline for these groups with participants who are asked to join the group can
be quite similar to that of the voluntary group, but because clients are frequently
coerced to attend these sessions, I suggest that counselors start with an exploration
of current actions. The conventional focus “What are you doing?” is best altered by
asking “What did the teacher, the administrator, or parent say you did? or, “What
did they think you did?” The counseling process is more likely to flow better after
the group members observe the counselor’s non-judgmental attitude.
GROUP PROCESS ISSUES
Counselors using reality therapy ensure group interaction by helping the members
identify commonalities, that they have similar wants and goals. Consequently,
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group members develop a sense of inclusion and eventually become more cohesive
as a group. Counselors facilitate participant interaction and mutual help based on
common goals, on similar past choices, on comparable self-evaluations, and on
parallel plans.
A word of advice: I suggest that group counselors have an outline, plan, or tentative strategy as they begin a group. However, the plan might not survive and will
need to be adapted and tailored to the development of the group. The process of a
group often does not follow a trail based on textbook models. Refer to chapter 12
for more about groups.
REALITY THERAPY IN THE CLASSROOM
Reality therapy can be used individually and in small groups. It can also be effectively
employed in large group meetings. “Class meetings provide a structure for discussion
of timely and relevant topics and are designed to help students satisfy one or more
of the five human needs or motivators” (Wubbolding, 2016, p. 285). In schools and
agencies, these meetings focus on intellectual discussions with the structure define,
personalize, and challenge. For example, counselors (group facilitators) help participants define friendship. They personalize the discussion by asking questions such
as, “How many friends do you need to be happy?” “What does being a friend mean
to you?” The facilitator then challenges them by asking such questions as “Why do
people need friends?”
Other class meetings are more action oriented and address social problems. For
example, the focus may be on improving safety on the playground or curtailing
shoplifting in the community. The facilitator asks questions such as, “What can we
do to increase safety on the playground?” or, “How can we address the complaint
of the local merchants that there’s too much shoplifting?” Children are invited to
discuss the problem and share their opinions about it, evaluate whether this is a
problem that needs to be addressed, and, through their discussions, they mutually
develop a plan to solve the problems. It is important to follow up on the plan at a
future time so that they can evaluate how the plan worked and, if it didn’t, discuss
other solutions and make a new plan. Glasser (2004) has developed a very helpful
resource, Glasser Class Meeting Kit: Choice Theory Curriculum, which can be used
in classrooms, mental health agencies, and other settings.
Read about a young client’s experience with a reality therapy approach in the
“Voices from the Field—Child” sidebar.
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VOICES FROM THE FIELD—CHILD
I am eighth-grade Senegalese immigrant. I was diagnosed with Asperger syndrome and I hate it because it makes me feel different from the other kids. I also
have a French accent and they make fun of me for that. When my mom took me
to counseling, the counselor asked what I didn’t like about my diagnosis, and I
told her that it has the word “ass” in it, and that makes me mad. The counselor
told me that Asperger is no longer a diagnosis. It is now called autism spectrum.
I liked that term a lot better. The counselor told me that labels can change and
that I can move along the spectrum over a period of time. She suggested that we
could work together and figure out things to do to make me feel better. She said
I have a lot of choices and that we both think about a useful motto, “KIS” “keep
it simple.” I told her that sounds great to me.
—Nuna, eighth grader
TAKE-AWAYS FROM CHAPTER 6
As we conclude this chapter, I would like to refer to the short vignette at the beginning
of the chapter and share what I learned from the teacher/counselor who worked with
a student with a behavioral problem. I learned that by using reality therapy children
can make more effective choices and therefore change from a pathway that might
lead them astray to a more beneficial pathway. In this vignette, the teacher/counselor asked the student to describe his actions and their impact on other students.
She inquired about whether this impact was desirable and whether his choices get
him in trouble, which was a very effective technique. The student evaluated his own
behavior and made more effective plans. The vignette also illustrates that talking to
young clients with the idea that they are internally motivated to satisfy their needs
is an alternative to external controls such as punishment, threats, verbal corrections
and other less effective methods. Even though this presenting issue appears to be an
everyday problem, the strategies are applicable to more severe problems. Keep in mind
that reality therapy began with very difficult clients in a correctional school for girls.
After reading this chapter, you should be more knowledgeable about these
key points:
•
The system of internal motivation: the five human needs that drive all behavior
•
The distinction between internal motivation and external control
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•
The fundamental principles of choice theory
•
The difference between choice theory and reality therapy
•
How to apply the WDEP system of reality therapy
•
Specific techniques for implementing the principle of self-evaluation
•
The rationale for using reality therapy with diverse populations
HELPFUL WEBSITES
www.realitytherapywub.com
www.real-choice.co.uk
http://wglasser.com
PRACTICAL RESOURCES
Glasser, W. (2011). Take charge of your life. Bloomington, IN: iUniverse.
International Journal of Choice Theory and Reality Therapy
Free Online Journal, Editor: Thomas Parish parishts@gmail.com
Wubbolding, R. E. (2017). Reality therapy and self-evaluation, the key to
client change. Alexandria, VA: American Counseling Association.
REFERENCES
American Counseling Association (2014). ACA Code of Ethics. Alexandria, VA: Author.
Frankl, V. (1963). Man’s search for meaning. Boston, MA: Beacon.
Fulkerson, M. H. (2015). Treatment planning from a reality therapy perspective. Bloomington, IN: iUniverse.
Glasser, C. (2009). Glasser class meeting kit: Choice theory curriculum. Los Angeles, CA:
William Glasser Inc.
Glasser, W. (1965). Reality therapy. New York, NY: Harper & Row.
Glasser, W. (1968). Schools without failure. New York, NY: Harper & Row.
Glasser, W. (1972). The identity society. New York, NY: Harper & Row.
Glasser, W. (1984). Control theory. New York, NY: HarperCollins.
Glasser, W. (1992). The quality school (2nd ed.), New York, NY: HarperCollins.
Glasser, W. (1993). The quality school teacher. New York, NY: HarperCollins
Glasser, W. (2000). Reality therapy in action. New York, NY: HarperCollins.
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Glasser, W. (2003). Warning: Psychiatry can be hazardous to your mental health. NY:
HarperCollins.
Neukrug, E. (Ed.). (2015). The SAGE encyclopedia of theory in counseling and psychotherapy.
Thousand Oaks, CA: SAGE.
Robey, P. A., Wubbolding, R. E., & Malthers, M. (2017). A comparison of choice theory
and reality therapy to Adlerian individual psychology. Journal of Individual Psychology,
73(4), 283–294. doi:10.1353/jip.2017.0024
Rotgers, F. (2012). Cognitive-behavioral theories of substance abuse. In S. Walters & F.
Rotgers (Eds.), Treating substance abuse theory and technique, (3rd ed.) (pp. 113–137).
New York, NY: Guilford Press.
Roy, J. (2014). William Glasser: Champion of choice. Phoenix, AZ: Zeig, Tucker, Theisen.
Wubbolding, R. E. (1988). Using reality therapy. New York, NY: Harper & Row.
Wubbolding, R. E. (2000). Reality therapy for the 21st century. Philadelphia, PA: Brunner
Routledge.
Wubbolding, R. E. (2011). Reality therapy: Theories of psychotherapy series. Washington,
DC: American Psychological Association.
Wubbolding, R. E. (2013). Reality therapy. In B. Irby, G. Brown, R. Lara-Alecio, & S. Jackson
(Eds.), The handbook of educational theories (pp. 481–489). Charlotte, NC: Information
Age Publishing.
Wubbolding, R. E. (2014). Reality therapy. In G. R. Vanderbos, E. Meidenbauer, & J.
Frank-McNeil (Eds.), Psychotherapy theories and techniques, (pp. 307–315). Washington,
DC: American Psychological Association.
Wubbolding, R.E. (2016). Professional school counselors and reality therapy. In B. Erford
(Ed.), Professional school counseling (3rd ed.), (pp. 279–289). Austin, TX: Pro-Ed.
Wubbolding, R. E. (2017). Reality therapy and self-evaluation, the key to client change.
Alexandria, VA: American Counseling Association.
Wubbolding, R. E., & Brickell, J. D. (2015). Counselling with reality therapy (2nd ed.).
London, UK: Speechmark Publishing.
Wubbolding, R., Casstevens, W., & Fulkerson, M. (2017). Using the WDEP system of reality therapy to support person-centered treatment planning. Journal of Counseling and
Development, 95(4), 472–477. doi:10.1002/jcad12162
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CHAPTER 7
Rational-Emotive Behavior Therapy
Ann Vernon
LEARNING OBJECTIVES
1.
To identify specific reasons why REBT is effective with children and adolescents
2.
To describe how to implement the ABC model with young clients
3.
To describe cognitive, emotive, and behavioral interventions for this population
Y
ears ago, Mrs. Chang made an appointment for help with stress management.
During the initial session, she explained that her husband was a physician
who worked very long hours, and, consequently, she had to assume all the
responsibility for running the household and taking care of their children, ages 8,
10, and 12. When asked to rate her stress on a 1–10 scale, she replied that most days
it was a 9 or a 10. After assessing how she experienced stress, I asked Mrs. Chang to
share more about the specific stressors so that I could have a better understanding
of what she was dealing with, which would help in developing a plan of action.
Mrs. Chang explained that her husband was quite particular about the way the
household was run, which meant that she spent long hours cleaning and preparing
nutritious meals while the children were at school. She said that as soon as they
arrived home from school she was quite stressed because she had to help each of
them practice the piano 30 minutes a day, supervise their homework, and then get
dinner on the table and lunches prepared for the next day.
After listening to the details about her day, I asked what she had done to help
alleviate the stress. She said that there was really nothing that she could do because
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the children needed her help and she had to keep things running smoothly at home.
She complained about never having any “me” time or time with friends because she
was so consumed by her responsibilities. “I really don’t know what to do, and I am
hoping that counseling might help,” she said.
As a rather inexperienced therapist who was eager to assist, I asked if she had
ever thought of hiring cleaning help, which I thought might be a small step in the
right direction. She said she had tried it a few times, but her husband thought it
was a waste of money and it wasn’t worth arguing with him because that really
elevated her stress level. Then I asked if she had ever thought about rotating the
piano practicing so that one day she would practice with the 8-year-old, the following day with the 10-year-old, and so forth, thus freeing up time for herself or
other duties. She immediately discounted that idea, saying that if she didn’t help
them they wouldn’t perform well in the piano recitals and others would think
she was an irresponsible parent. This same line of thinking applied to helping the
children with their studies.
I worked with this parent before I really started to practice rational-emotive
behavior therapy (REBT). Had I known better, I would have readily picked up on
the “good mother should” theme and could have predicted that she would shoot
down my brilliant suggestion of rotating piano practice and homework help. After
I realized that she would “yes, but …” any practical problem-solving ideas, I read
more about REBT and turned the sessions in a different direction. Read more about
this at the end of the chapter!
The purpose of this chapter is to present information about the basic principles
and practices of REBT as they specifically apply to children and adolescents. In
addition, this chapter contains information about the educational derivative of
REBT, rational-emotive education (REE) in classrooms and small groups, as well
as REBT applications with parents and teachers.
RATIONAL-EMOTIVE BEHAVIOR THERAPY:
AN OVERVIEW
From its inception, Albert Ellis pioneered the application of REBT with children and
adolescents. I remember meeting with him and several other REBT colleagues who
specialized in applications of the theory with young clients in his apartment at the
Albert Ellis Institute many years ago. We were discussing REBT as a preventive emotional health program, and Dr. Ellis was adamant about the importance of teaching
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children and adolescents positive mental health concepts that would enhance their
emotional, social, cognitive, and behavioral development. He thought that it should
be introduced in educational settings, stating that he had “always believed in the
potential of REBT to be used in schools as a form of mental health promotion and
with young people experiencing developmental problems” (Ellis & Bernard, 2006,
p. ix). His conviction resulted in the Living School, which opened in the basement of
the Institute for Rational-Emotive Therapy in 1971, established to help young people
learn rational concepts that were integrated into the regular elementary curriculum
(Vernon, 2009a). In its five years of existence, teachers found that teaching REBT
principles to students improved their mental health. To broaden the impact, the
school closed in 1975 and the Rational-Emotive Education Consultation Service
was established, with the goal of providing workshops to teachers, counselors, and
school psychologists regarding the implementation of rational-emotive education
(REE) (Bernard, Ellis, & Terjesen, 2006).
REBT has been applied effectively and extensively with children and adolescents,
both for intervention as well as prevention, for well over 6 decades (Vernon, 2009a). I
became interested in REBT when using client-centered therapy with younger clients
in a school setting didn’t seem to help them “get better.” I knew that they felt better
after having talked about their issues, but they returned week after week with similar
problems, just with a different person or situation. After attending a series of REBT
trainings at the Albert Ellis Institute in New York, I began applying the principles
with Larissa, a fifth grader who had difficulty getting along with her friends and
siblings. I started looking for irrational beliefs in the form of demands—my friends
and sisters should always let me have my way and they should always treat me exactly
as I think they should. By asking her a series of questions, I helped her understand
that she couldn’t really control others, and although it would certainly be preferable
if they always let her have her way, was it realistic to think that it could always be this
way? After several sessions, Larissa realized that her demanding only escalated the
conflict and that her anger wasn’t helping her achieve her goal of getting along well
with her friends and her sisters. Once we addressed the demanding, which was the
crux of the problem, we not only solved the current problem, but other problems
related to her demands. This is an example of how REBT helps clients “get better,”
not just “feel better,” because the core irrational thinking patterns that create the
emotional upset are the focus of the counseling sessions.
When I began to see how effective this theory was, I realized that at that time
there were very few specific REBT interventions to use with children and adolescents
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other than a prevention program, Rational-Emotive Education: A Manual for Elementary School Teachers (Knaus, 1974), so I began developing my own. I published
Help Yourself to a Healthier You (Vernon, 1980), Thinking, Feeling, Behaving, with
separate volumes for children and adolescents (originally published in 1989 and
revised in 2006), What Works When with Children and Adolescents: A Handbook
of Individual Counseling Techniques (2002), and More What Works When (2009b).
In addition, Michael Bernard has developed materials for children and adolescents
that focus on the link between academic achievement and social-emotional growth
with his Program Achieve: A Social-Emotional Learning Curriculum for Young
Children (2018a) and A New Program Achieve (2018b). Now there are numerous
specific techniques to help young clients learn REBT concepts in their “own language,” thus making it possible for them to apply the basic theoretical concepts
to typical developmental problems as well as to more serious issues. No longer is
REBT simply a “downward extension of REBT adult methods” (Ellis & Bernard,
2006, p. xi).
RATIONALE FOR USING REBT WITH CHILDREN AND
ADOLESCENTS
For many compelling reasons, REBT is a very effective theoretical approach with
young clients. First, children’s sense of time is “the here and now,” so a problem
today might not be a problem tomorrow. Because REBT immediately addresses
the issue and is generally a briefer form of therapy, it is well suited for this age
group. Second, children and many adolescents are concrete thinkers. As such, their
capacity for logical thinking, perspective taking, and problem solving is limited.
REBT counselors use numerous concrete strategies that help young clients learn
and apply basic REBT principles. Furthermore, this theory is very developmentally appropriate in that it involves young clients in “doing” and “seeing” as much
as “hearing,” which is very important (DiGiuseppe and Bernard, 2006; Vernon,
in press).
The fact that it is a psychoeducational approach is another reason this theory
works so well with younger clients. In addition to active listening, REBT practitioners routinely teach relevant concepts that help clients learn such things as the
difference between facts and assumptions, where feelings come from, and how to
control thoughts, feelings, and behaviors. In other words, if something isn’t clear,
the REBT therapist offers simple explanations, as I did with 12-year-old Shaniqua
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who assumed that if her best friend Keisha spoke to other classmates or sat with
them at lunch that Keisha no longer liked her. I explained the difference between a
fact and an assumption to Shaniqua and then asked her if she had 100% proof that
Keisha didn’t like her if she sat with others or associated with anyone other than
Shaniqua. She said that she didn’t have 100% proof. Then I asked her if she ever spent
time with anyone other than Keisha and she said of course. “So, if you associate with
others, do you still consider Keisha your best friend?” “Sure,” she replied. “Then do
you suppose that it is possible that Keisha still considers you to be her best friend
even though she also has other friends?” The discussion went on in this manner
and I helped her understand that assuming Keisha didn’t like her without checking
out the facts could be detrimental to the friendship.
Another important reason to use REBT with this population is that this theory
teaches young clients what they realistically can and cannot control in their lives.
Children and adolescents don’t choose to be abused, bullied, live in dysfunctional
families, and so forth, and while they may not be able to change those realities,
REBT teaches them how to control their thoughts, feelings, and behaviors, which
empowers them to deal more effectively with problematic situations. For example,
8-year-old Juanito was very upset about his father being deported, because although
he and his mother lived in the country legally, his father did not and was forced
to return to Mexico. Through working with him, I helped him see that while this
situation was clearly very difficult, his dad was choosing to obey the law and would
do everything he could to be able to return to this country legally. We talked about
how Juanito’s reaction to the situation, which he expressed through anger and acting
out, was only creating problems at home and school, and it wasn’t helping his dad
stay in the country. Once he understood that he had no control over the situation,
we worked on his anger and he began to focus on what he could control, such as
writing to his dad, talking to him on the phone when possible, and studying hard
to make his dad happy. While this wasn’t the ideal solution, the reality is that many
children and adolescents have to deal with very difficult situations, such as this one,
and REBT helps children think more rationally so they can focus on what they can
do to make the best of a bad situation.
Another advantage of REBT is that it teaches emotional and behavioral self-control
by helping children and adolescents understand the reciprocal connection between
thoughts, feelings, and behaviors. Furthermore, it uses a wide variety of cognitive,
emotive and behavioral techniques to teach the basic principles. REBT is applicable
in many different settings, including schools and mental health centers. In addition,
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the fact that it can be used not only in individual counseling, but also in small group
and classroom settings, speaks to its versatility.
Finally, there is a good deal of research to support the effectiveness of REBT with
youth. Gonzalez and colleagues (2004) conducted a meta-analysis of REBT with
children and adolescents and found that the average child or adolescent scored 69%
better than untreated control groups on several outcome measures. They found
that REBT is especially effective in treating young clients with externalizing disorders and that it is useful in both intervention and prevention. Results from a more
recent meta-analysis (Esposito, 2009) confirmed the 2004 findings that REBT is an
empirically supported treatment for various emotional and behavioral problems
experienced during childhood and adolescence. There is also good empirical support
for rational-emotive education (REE) in schools. In fact, REE is one of the oldest
social and emotional learning programs (e.g., Knaus, 1974), with extensive research
attesting to its effectiveness and qualifying it as a best, evidence-based practice
(Bernard, 2006; Vernon & Bernard, in press).
KEY THEORETICAL CONCEPTS
AND BASIC PRINCIPLES
The primary goal in applying REBT with children and adolescents is to help them
learn rational principles that they can employ to reduce emotional distress and
change self-defeating behaviors. The emphasis on teaching and prevention is one
of the distinguishing features of this approach (Vernon, in press). Wilde (1992)
describes REBT as “arming” young clients with knowledge and skills that they can
use in the present as well as in the future. There are several core concepts that can
be readily adapted to help children and adolescents learn the essence of the theory,
described as follows:
EMOTIONAL AND BEHAVIORAL PROBLEMS RESULT FROM
IRRATIONAL BELIEFS
Children commonly attribute emotional and behavioral reactions to an event or
another person: “She made me mad,” or “I hit him because he called me names.”
In reality, it is not an event or another person that makes them feel or behave as
they do. Rather, their beliefs result in the emotional and behavioral reactions. I
explained this concept to 9-year-old Ashira, as illustrated in the “Dialogue Box”
sidebar.
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DIALOGUE BOX
COUNSELOR: “So, Ashira, I want to help you understand that other
kids or situations don’t make you feel and act a certain way, so I am
going to tell you a story. Imagine that you and your cousin are going
to an amusement park. You are really excited about riding on the
roller coaster, but your cousin is very scared. It is the same situation,
but the two of you feel differently about it. Why do you think that is?”
CLIENT: “I don’t know. I guess she is just scared.”
COUNSELOR: “Well, you aren’t scared, so what are you thinking
that makes you so excited?”
CLIENT: “That this will be lots of fun!”
COUNSELOR:“So what do you think your cousin might be thinking
that makes her so scared?”
CLIENT: “I guess she might be thinking that we will crash or that we
will get stuck at the top and never get down, or something like that.”
COUNSELOR: “Exactly. So, can you see that it is not the situation,
since it is the same roller coaster ride, but what you are thinking that
makes you excited or scared?”
FEELINGS CHANGE WHEN THOUGHTS CHANGE
This can be a very empowering concept for young clients to learn and it can be taught
in several different ways. For example, I was teaching a classroom guidance lesson
and divided the class into two groups. I gave each child in the first group an apple
but gave nothing to the second group. I asked the children in the first group how
they felt about receiving the apple, and of course they were all happy about it. The
children in the second group complained that it wasn’t fair that they didn’t get an
apple and they were angry. Then, I said that the apples were actually rotten and asked
the children in both groups how they felt. The feelings were reversed! I explained
that their feelings changed because they gained new information that changed their
thinking—in this case, when they learned that the apples were rotten, those who had
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gotten them didn’t feel good about it, while the others were then relieved that they
hadn’t gotten one. This concept can be explained in many different ways.
RATIONAL AND IRRATIONAL BELIEFS
Because the terms rational and irrational can be confusing for younger clients, I
oftentimes use words such as helpful and unhelpful, or hot thoughts, cool thoughts. In
essence, rational beliefs are true and supported by evidence. They result in healthy
negative emotions such as disappointment, worry, sadness, and irritation. They are
preferences rather than absolutistic demands. Rational beliefs are flexible, result in
constructive behaviors, and help clients achieve their goals. In contrast, irrational
beliefs are untrue, based on assumptions, and are inconsistent with reality. They
are rigid and illogical, resulting in strong negative emotions such as depression,
anger, anxiety, resentment, self-pity, worthlessness, and rage, as well as in maladaptive behaviors such as avoidance, withdrawal, procrastination, and other forms of
acting out (DiGiuseppe, Doyle, Dryden, & Backx, 2014). They do not result in goal
attainment.
There are five types of irrational beliefs: demandingness, frustration intolerance,
awfulizing, self-condemnation, and other-condemnation (DiGiuseppe et al., 2014).
Demandingness implies that people or events must be exactly how the individual
wants them to be; it is an absolutistic expectation. Frustration intolerance is the
notion that everything in life is easy and people shouldn’t have to work too hard for
anything or experience any discomfort. According to DiGiuseppe and colleagues
(2014), awfulizing is when the negative consequences of something are exaggerated to the extreme, such as “It’s so awful that he calls you names,” or, “It’s awful
she can’t come to your party.” (Is it really awful?) Self-condemnation relates to the
notion that individuals must be perfect, infallible human beings who never make
mistakes and, if they do, they are awful and worthless. Other-condemnation applies
the same principles to others. This global evaluation of self or others implies that
human beings can be rated as good or bad, which is an anti-REBT concept. Rather,
REBT practitioners rate individual attributes, not the whole person. In working
with children, I often use a pie chart (see Figure 7.1) to help illustrate this concept.
I explain that instead of thinking that they are not good in any school subjects,
they can rate each subject separately so they learn that while they may not do well
in science, they perform better in math, quite well in languages, and so forth. The
goal is to avoid global self-rating.
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Science
Social
Studies
Math
Language
Arts
Art
Physical
Education
FIGURE 7.1 Performance wheel.
Virginia Waters (1982, p. 572) identified more specific irrational beliefs in children:
1.
It’s awful if others don’t like me.
2.
I’m bad if I make a mistake.
3.
Everything should always go my way; I should get what I want.
4.
Things should come easy to me.
5.
The world should be fair and bad people must be punished.
6.
I shouldn’t show my feelings.
7.
Adults should be perfect.
8.
There’s only one right answer.
9.
I must win.
10.
I shouldn’t have to wait for anything.
Waters (1981, p. 6) also enumerated the following irrational beliefs for adolescents:
1.
It would be awful if my peers didn’t like me. It would be awful to be a social loser.
2.
I shouldn’t make mistakes, especially social mistakes.
3.
It’s my parents’ fault I’m so miserable.
4.
I can’t help it. That’s just the way I am, and I guess I’ll always be this way.
5.
The world should be fair.
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6.
It’s awful when things don’t go my way.
7.
It’s better to avoid challenges than to risk failure.
8.
I must conform to my peers.
9.
I can’t stand to be criticized.
10.
Others should always be responsible.
It is important to remember that just because a problem exists does not automatically mean that irrational beliefs are causing the negative emotional and behavioral
reactions. For example, it is reasonable to assume that if a young client’s grandparent dies, he or she will be very sad and cry from time to time, which would be an
appropriate emotional reaction. But if the client won’t eat, isolates him- herself for
days on end, and refuses to go to school for several weeks, it is likely that the client
is thinking that this is the worst thing that could ever happen, that he or she can
never be happy again, and that the situation is unbearable. The REBT counselor
would be very empathic and help the client mourn the loss of the grandparent, but
also help him or her think more rationally about the situation.
It is critical to use developmentally appropriate strategies such as games, music,
literature, puppets, and so forth when teaching children and adolescents about
these two types of beliefs. For example, I was working with an 8-year-old who awfulized about everything. I first had him read It Could Have Been Worse (Benjamin,
1998). After he read it, we discussed the story, noting that even though some bad
or unfortunate things happened to the main character, he always assumed that “it
could have been worse.” I asked him if he could cite any examples like that from
his own life where things could have been worse, and he managed to come up with
several. I like to reinforce concepts in several different ways, so I used a technique
that is described in the “Add This to Your Toolbox” sidebar.
ADD THIS TO YOUR TOOLBOX
After reading the book about how things could have been worse, I handed
my client a pair of glasses with dark lenses, which I explained were “doomand-gloom” glasses, and that when he wore them, everything would seem
awful. I gave him several scenarios, such as going to a party, taking a test,
playing basketball, and so forth, asking him to verbalize how “awful” each
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of these events would be. Then I asked him to take off the doom-and-gloom
glasses and handed him a pair covered with pink lenses, explaining that
when he wore these rose-colored glasses, everything would seem wonderful. I gave him the same scenarios and asked him to once again verbalize
what each situation would be like. When he was finished, we talked about
the difference between the two sets of glasses and the fact that things usually didn’t look as great as they did when he was wearing the rose-colored
glasses. However, if he didn’t wear the doom-and-gloom glasses and instead looked at things clearly, would everything be so awful?
Similar methods can be used to explain demands against self and others and
frustration intolerance. I often use the story by Wally Piper (1986), The Little Engine
that Could, with young clients who have frustration intolerance and lack persistence.
I couple this with a song I wrote (Vernon, 2009b, p. 177) to further illustrate the
concept:
I can’t stand it, I can’t stand it, no I can’t, no I can’t
This is just too boring, I just feel like snoring,
I can’t stand it, I can’t stand it.
(The second verse conveys the rational belief):
I can stand it, I can stand it, yes I can, yes I can!
I don’t have to like it, I just have to do it,
I can stand it, I can stand it.
(To the tune of Are You Sleeping?)
THE A-B-C MODEL
Ellis developed the A-B-C model to illustrate the basic constructs of the theory as
well as the process of change (Hickey & Doyle, 2018). In this model, the A stands
for the activating event, which can be positive or negative, although they are usually negative. Activating events can be real or perceived; they can be something
that happened in the past, something that is happening right now in the present,
or something that the client perceives happened or will happen in the future. As
previously noted, children and adolescents in particular strongly believe that it is
the activating event that causes their emotional and behavioral reactions (Vernon,
2016). However, it is not the activating event (A) that creates the emotional and
behavioral consequences (C), but rather, the beliefs (B’s) about the activating event.
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Although the activating event can certainly contribute to the consequence (C), the
reality is that two different people can experience the same event and feel and react
differently based on their beliefs. For example, I remember when my son and his
friend didn’t get invited to a neighborhood birthday party. Nick was really upset
and said that it wasn’t fair, but my son Eric said that he wasn’t that upset because
he just figured that his friend’s mother only let him invite a certain number of kids
to the party and it wasn’t a big deal. Different beliefs about the same event resulted
in different emotions.
The D in the A-B-C model is disputation, which is the “heart and soul” of the
REBT process. It is through disputation that clients learn how to replace irrational beliefs with rational thoughts. This can be rather challenging for children
and adolescents, but there are numerous interventions that help them learn the
“what and how” of disputation. It is important to use concrete techniques and a
psychoeducational approach. I often use the metaphor of “erasing” the irrational
beliefs, and one of my young clients developed the idea of “changing the channel” on the radio in his head when he started to think unhelpful thoughts! Other
techniques include depositing your “junk thoughts” in a “junk thought can” or
waving a magic wand that replaces irrational beliefs with rational thoughts. These
metaphors make sense to young clients. Disputation will be discussed in greater
detail later in the chapter.
The E in the A-B-C model stands for effective new thoughts, feelings, and behaviors—in other words, if they think more rationally, they will have healthy negative
emotions and adaptive behaviors. In the E, we want to reinforce rational concepts
so that clients learn how to avoid rating themselves or others globally and realize
that they do not have to be perfect human beings who are loved and approved of by
everyone. Teaching children how to avoid catastrophizing as well as how to tolerate
frustration and put problems in perspective is also critical. It is also important that
they learn to differentiate between demands and preferences and understand that
they may want something but not necessarily need it. I explained this concept to
my granddaughter when she was 3 years old. She was taking a bath and told me
that she needed more bath bubbles. I said, “Elia, you don’t need them, you just
want them!” “No, Nanna, I need them,” she said. We went back and forth like this
for a few minutes. Several days later I told her that I had ordered a magazine for
her with lots of stories and pictures and games. I asked if she had gotten it yet and
she said “No, Nanna, but I don’t need it. I have lots of ‘magzines’” (she couldn’t
pronounce magazines)! Two years later I overheard her younger brother say that
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he really needed something, and Elia said, “No, Niko. You don’t need it; you just
want it!” She is now 11 years old, and on a recent shopping outing she asked me if
I needed the dress I admired in the store window or just wanted it. This is just an
example of how it is possible to teach rational principles to very young children.
Various other methods of helping young clients achieve the E are described later
in the chapter.
THE C.A.T. MODEL
I developed the C.A.T. model as a model within the A-B-C model to explain in
more detail how to apply this process with children and adolescents. In the C.A.T.
model, the C stands for connect, which is extremely important when working with
this population; the A stands for assess; and the T refers to teach and treat.
THE C: CONNECT
Particularly when working with children, developing a strong therapeutic alliance is extremely important (DiGiuseppe & Bernard, 2006; Vernon, in press).
According to Bernard, Ellis, and Terjesen, (2006), “It has always been recognized
by child and adolescent-oriented REBT practitioners that a warm, supportive,
empathic, relationship with young people is a necessary condition for the full
benefits of REBT interventions to be realized” (p. 27). These authors emphasize
the importance of listening and offering unconditional positive regard, being
honest and patient, working on winning respect, and showing genuine interest
in the client’s life.
Building rapport is essential for several reasons. First, children and adolescents are
often referred by someone else and therefore may be more reluctant or resistant to
engage in the counseling process. Second, because counseling may be a new experience, they might be anxious. In addition, counselors can learn a lot about the client
by engaging in some simple rapport-building activities and use this information
in later sessions, making concepts more personal and meaningful. For example, I
played “Flip the Coin” with a young client (Vernon, 2002) and learned that he was
a good soccer player. In a later session when he was putting himself down, saying
that he wasn’t good at anything, I reminded him that he had told me during the
game that he was good at soccer. “Did I just imagine that you said that?” I asked.
“No,” he said, “I actually am good at soccer.”
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Games, movement activities, art and music are good rapport-building activities
that put younger clients more at ease and thus make the counseling sessions more
productive. For example, play “Jellies in a Jar,” where you and the client take turns
picking out a jelly bean from a jar, drawing a color-coded card that matches the
color of the jelly bean, and finishing the sentence “Something I would wish would
happen is …”; “Something that comes easy to me is …”; and so forth. Some older
adolescents may not respond as well to games, but you could alternate back and
forth and finish the sentence “I am someone who …”(drives a red car, doesn’t like
ice cream), for example, or carry on a conversation with each other by only using
declarative statements, such as “I like pork tenderloins; I like to sing.” For numerous
examples of get-acquainted activities, refer to What Works When with Children
and Adolescents (Vernon, 2002) and More What Works When with Children and
Adolescents (Vernon, 2009b).
THE A: ASSESS
In the C.A.T. model, the A stands for assessing the activating event (A), the emotional
and behavioral consequences (C’s), and rational and irrational beliefs (B’s). There are
various age-appropriate ways to do this by employing creative arts interventions,
props, and other concrete strategies to make this assessment process understandable
to young clients.
Assessing the Activating Event
Younger clients often shrug, saying “I don’t know” when asked what the problem is.
It may be true that they really don’t know, especially if they have been referred by
others. Assuming that a teacher or parent has told you the reason for the referral,
I prefer to say to the young client, “Your teacher said that you are having trouble
getting your work done and thought I could help you with that,” rather than beat
around the bush and try and pull a response from the client. With younger children, it may be more effective to ask them to draw a picture of the problem, show
you with puppets, or pretend they are telling you a story about the problem. With
adolescents who may not be forthcoming, I often have them read a short story
written by another adolescent whose problem is similar to theirs. For example, I
worked with teenager who was struggling with depression but was unable to really
describe how she felt. I invited her to read Will I Ever Feel Better? (Vernon, 1998)
and she was able to identify with the content and talk more about how she was
experiencing depression.
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Assessing the C: Emotional and Behavioral Consequences
Once you have a clear picture of the problem, the activating event, you ask how the
client feels about the problem (the emotional C). It may be necessary to use some
psychoeducation with younger clients who may not have a well-developed feeling
vocabulary. Sharing a short list of feeling words and having the client circle words
that apply to him or her, asking him or her to act out the feeling, or playing a feeling game may be necessary. Adolescents usually have a broader feeling vocabulary
but may be reluctant to admit to having certain emotions. In this case, I might say,
“Suppose you did feel anxious, what do you think that might be like?” Bibliotherapy
or cinematherapy may also be helpful.
It is especially important with children and adolescents to ask how they behaved
in relation to the feeling (the behavioral C) because it is often easier for them to
describe how they behaved rather than how they felt. So, I frequently come “through
the back door,” so to speak, by asking them what they did when they had a fight
with a friend, for example, and then infer the feeling if they aren’t able to specify
it. Another reason to ask about the behavior is that it helps clarify the feeling,
resulting in a more accurate assessment. For instance, suppose a young client says
he was sad when his friend called him a name, but when asked how he behaved
when he felt sad, he said he hit him. I can confront the discrepancy by saying, “If
you hit your friend, it sounds like you were mad, not sad. Because if you felt sad
you might cry or stay away from your friend, but you probably wouldn’t hit him.
Does that make sense? Can you tell me how you felt?” Using psychoeducation in
this way helps clients be more specific and accurate with regard to the emotional
and behavioral consequences.
Assessing the B: Beliefs
Assessing beliefs (B’s) is the next step, and this can be a challenge with both children
and adolescents. Typically, we would ask adult clients what they were thinking when
they felt angry, but if you use this approach with younger clients, they may give you
a blank look and not be able to tell you what they were thinking. Asking “What was
going through your head when you felt so anxious” might be helpful, but they still
may need more help with identifying thoughts. Using a head with thought bubbles
is a good concrete strategy, as illustrated in Figure 7.2.
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I might say to the client, “Imagine
that you are back in the classroom and
you just got a test back with a failing
grade. You said you were really upset.
What was going through your head at
that very moment?” You may need to
prompt them and even offer some inferences, such as “Some kids your age might
think they’re stupid or that they’ll never
pass a test again. Did you have any of FIGURE 7.2 Thought bubbles.
those thoughts?” It is quite probable that
the inferences are correct but the client
just isn’t able to verbalize them. It takes patience and some probing to help young
clients identify their beliefs, and what they often do is identify automatic thoughts,
which then need to be “translated” into core irrational beliefs (demands, awfulizing,
frustration intolerance, and self/other condemnation/global evaluation). For example,
if an adolescent says that she doesn’t like it when her parents restrict screen time
and she has identified anger as the emotion, I would say “If you just didn’t like it you
probably wouldn’t feel angry, so I am wondering if you might be thinking something else, such as they shouldn’t treat you like this, and it isn’t fair that they are so
restrictive?” Dialogue of this nature is usually necessary when assessing irrational
beliefs, and you aren’t putting words in their mouths because anger is associated
with fairness and demands on others.
To detect irrational beliefs, the REBT counselor must listen discriminately to
everything the client says. For instance, when a teenager says, “I’ll never get a date. …
I’m a social misfit,” he is overgeneralizing, and, in this case, he is also engaging in
self-downing. Or, if an adolescent says that it will be the end of the world if she isn’t
chosen as the class president, she is awfulizing. Statements such as “I can’t stand
to take tests”; “It’s too hard to study”; and “It’s too boring” indicate frustration
intolerance, as reflected in the irrational belief that everything should come easily
and they shouldn’t have to do things that are too difficult or boring. You can also
identify irrational beliefs through emotional and behavioral reactions. For instance,
anger is related to a demand about other people or situations and guilt is a demand
against self—“I should.”
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THE T: TEACH AND TREAT
After assessing the activating event, the emotional and behavioral consequences,
and the beliefs, it is time to dispute the irrational beliefs. It is also important to help
the client identify new effective ways of thinking, feeling, and behaving, the D and
E of the A-B-C model.
Disputing (D)
Successful disputation results in healthy thinking, which facilitates problem solving
and goal setting. There are several types of disputes that can be very effective with
children and adolescents: empirical, functional, and logical disputes. An empirical
dispute asks for the evidence: “Where’s the evidence that if you fail this test you will
never get into college?” “Where’s the evidence that nobody, not one single person,
likes you?” A functional dispute asks how it is helping them to think irrationally:
“You just told me that you get really anxious before taking an exam because you
think you always have to get a perfect score, and if you don’t, it proves that you are
stupid. Are those thoughts helping you?” “You said that you get very angry when
your parents don’t let you do what you want, but when you throw tantrums, they
make you stay in your room for hours. Is it really helping you to continue to think
that you must always get your way even though you would like to?” The logical
dispute might be a bit more difficult for some young clients whose ability to see
cause and effect is limited: “How logical is it for you to think that you should get
good grades without having to study?” “Is it really logical to think that just because
your girlfriend broke up with you that you are a loser?”
Refer to the “Now Try This!” sidebar and try identifying and disputing your own
irrational beliefs.
NOW TRY THIS!
To be successful in using REBT with clients, you first need to use it on yourself
so that you fully understand the concepts. Think about a problem you have
and identify the situation (activating event), the emotional and behavioral
consequences, and the beliefs. After writing this down, try disputing your
irrational beliefs, using empirical, logical, or functional disputes. Were these
disputes helpful in clarifying your thinking differently about the problem?
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There is another type of dispute, the philosophical dispute, which is typically not
feasible for younger children or even teenagers whose abstract thinking skills are
still limited (Bernard et al., 2006). The philosophical dispute assumes the worst-case
scenario, so when an 8-year-old said that his father had moved to another state to get
a better job and he was afraid he would never come back, I could have said, “Suppose
he doesn’t ever come back, can you think of anything worse?” This is what Ellis
would term an elegant dispute, but you can see how a dispute of this nature would
be difficult and inappropriate for children and young teens. So, while it is preferable
to help children deal with reality because what the child is thinking could be true,
counselors must use their best judgment. If philosophic change isn’t feasible, it can
be very helpful to challenge inferences or encourage behavioral changes.
Non-preferential Disputing
With children and adolescents, we use logical, empirical, functional, and philosophical disputes as appropriate, as well as other non-preferential techniques, which
dispute automatic thoughts and inferences, not core beliefs. For example, it is very
important to teach children the difference between facts and assumptions, because
when they act on their assumptions, it can start a whole chain of negative reaction.
When I was a school counselor, I was walking through the hallway one day and
overheard two adolescent girls talking. One of them asked, “Did you see him in the
lunchroom? Was he with anyone?” The other girl said yes, she had seen him, but
she didn’t think her friend would want to know who he was with. I walked on by
as they continued talking, and when I returned to my office, one of the girls was
in the outer office with a boy I assumed was or had been her boyfriend. She was
yelling at him, accusing him of “being” with another girl in the lunchroom and
swearing that she was going to break up with him. He unsuccessfully tried to get a
word in edgewise, so I intervened, inviting them into my office so we could discuss
the situation more calmly. I used the “one person at a time” technique, explaining
that they would both get a chance to talk but they could not interrupt each other
until I gave permission, and then they had to first summarize what they heard the
other person say, specify what they agreed with, and then they were allowed to ask
questions. What emerged from this discussion was that he was talking to another
girl in the lunchroom who happened to be his cousin! The assumption the friend
made, which was that he was “with” someone else, fueled the fire. Had they not
come to my office where I could help them verify the assumptions, one or the other
could have acted impulsively and made matters worse.
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Other non-preferential practices include helping young clients learn how to identify alternatives and evaluate consequences. This is extremely important since they
make important decisions that can have significant negative consequences, such as
engaging in unprotected sex, using drugs, stealing, and so forth. Teenagers have what
psychologist David Elkind (1998) called the personal fable, meaning that bad things
can happen to others but not to them because they are special and invulnerable.
This type of thinking can be detrimental when coupled with their impulsivity, so
it is extremely helpful to help them think through consequences, as the following
case illustrates:
I was counseling 17-year-old Alex who thought that his parents were so controlling
that he couldn’t stand to live at home anymore. In reality, the parents were normal
parents with reasonable rules, but Alex refused to see that. He and his parents were
constantly arguing, and after he threatened to move out, they requested a session
with me. Naturally they were concerned, but it seemed as if the more they resisted
his desire to move out, the more argumentative and adamant he became, even
threatening to run away. After listening to the parents’ concerns, I suggested that we
employ a paradoxical technique, in which they would encourage him to move out as
long as they had assurance that he would be alright. We discussed some strategies
and scheduled an appointment that would include Alex.
When they arrived the following week, I told Alex that his parents had changed
their minds and thought it was a good idea for him to move out, but they needed
some assurance that he would be able to take care of himself and continue going to
school, so they had prepared some questions. They asked where he would live, how
he would pay for food and utilities, how he would get to and from school and work,
and so forth. Initially he said he could live rent free with some college friends, but
when pressed, he wasn’t sure they would pay the utilities. He said he could eat at
McDonald’s for free since he worked there, and he could increase his hours, driving
there immediately from school. At this point his mother interrupted and said that
he would not have access to the family car if he chose to move out. Although Alex
looked a bit shocked, he said he would just ride his bike. His dad pointed out that
it might be a bit difficult in the ice and snow, but it was certainly worth a try. By
the end of the session, the parents told Alex that while they supported the move,
he first needed to do some fact-finding about exactly what he would have to pay for
utilities, rent, and so forth, and asked him to think carefully about riding his bike,
eating McDonald’s food every day, and so forth. When the three of them returned
the following week, Alex said he had decided not to move out!
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Reframing is another helpful strategy to use with children and adolescents because
it opens their minds to other possibilities, which is useful for concrete thinkers. One
of my clients was convinced that her boyfriend was cheating on her because he had
ignored her most of the day. “Do you suppose there is any other reason he ignored
you today? Is it possible that he doesn’t feel well or that there was a conflict at home
or with a friend that has caused him to be preoccupied?” Often, children and adolescents do not consider other alternatives, and this leads to erroneous assumptions
and compounds the problem.
It is also very important to teach young clients about typical cognitive distortions
that contribute to irrational thinking (Beck, 1988). Consider the following examples:
•
Overgeneralization—blowing things out of proportion: “I’ll never get this
done”; “He’s always mean”; “I’ll never be a good musician”
•
Arbitrary inference—attributing a reason to something without having evidence. A teenager was asked to take care of her younger sisters while her
parents went to a movie, saying that they would be home around 10 p.m. They
returned at 9 p.m. and she attributed their early arrival to a lack of trust in
her, when, in reality they didn’t like the movie
•
Tunnel vision—only looking at a small aspect of the situation and ignoring
other salient details, such as only seeing a failing grade on an exam and forgetting that this was the first bad grade in that class
•
Negative labeling—calling themselves losers, morons, or other negative labels
•
Personalization—taking everything personally, such as thinking that when
the teacher did not call on him or her in class it was because the teacher didn’t
like him or her or thought he or she couldn’t answer the questions, when, in
reality, the teacher didn’t see his or her raised hand
•
Exaggeration—overstating something, such as when my son at age 8 complained that all he ever did was practice the piano. I asked, “So you don’t
eat, sleep, play, go to school, or ride your bike?” “Well,” said Eric, “I guess
I’m exaggerating”
As you can see, these types of cognitive distortions cloud young clients’ ability to
think clearly and rationally, so it is very helpful to work with them to identify and
dispute them. Doing so helps children and adolescents deal with future situations
where they exaggerate, personalize, and so forth. Based on experience, I can vouch
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for the fact that once clients understand these distortions they begin to “catch themselves” when they start to think like that again, which allows them to respond to
their situations more rationally. Once again, it is important to use developmentally
appropriate strategies. In the “Personal Reflection” sidebar, you are encouraged to
think about the irrational beliefs and distorted cognitions you had as a child or
adolescent and what effect they had on a specific event.
PERSONAL REFLECTION
In this chapter, you have been reading about irrational beliefs and cognitive
distortions. Review these and reflect on which of these were problematic
for you when you were a child or an adolescent. Identify a specific situation
and think about how that situation might have turned out differently if you
had been thinking rationally. Would things have been better?
Effective New Thoughts, Feelings, and Behaviors (E)
As previously noted, the goal of disputing is to help children and adolescents develop
more rational ways of thinking, which in turn impacts their feelings and behaviors.
With young clients in particular, reinforcing rational concepts after disputation is
imperative and can be done in many different ways. Some of my favorite interventions include having them take pictures of things they think they can’t stand and
put them in a scrapbook (frustration intolerance). Then, encourage them to try
doing what they think they can’t stand, and if they actually can stand it or tolerate
it, they tear that sheet out of their scrapbook, with the goal being to eliminate as
many pages as possible. I also like to use the chain reaction activity (Vernon, 2006b)
to help young clients understand the connection between how they think, feel, and
behave. To illustrate, take a strip of paper and write down an activating event, such
as needing to study for an exam. Then, take another strip and have the client identify
what he or she is thinking: “I shouldn’t have to study; it’s too boring to memorize
this; I shouldn’t have to waste time on this and miss out on fun with friends.” These
should be written on separate strips of paper. Next, have him or her write what he or
she did as a result of thinking that it was boring, he or she shouldn’t have to study,
and so forth (he or she didn’t study), and the result of that decision (failed the test).
Then, have him or her identify on separate strips the consequences of failing the
exam—had to stay after school, was grounded, missed a party, and so forth. Staple
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these strips together as in a paper chain and have the client hold it up to see how long
it is. Then, take the same activating event and ask him or her to imagine that instead
of thinking he or she shouldn’t have to study, he or she realized that even though
he or she didn’t want to, he or she wanted to pass the test, so he or she changed his
or her thinking, studied, passed the test, and there were no negative consequences.
An activity such as this really helps concrete thinkers understand how changing
their thinking can impact their behavior.
Other ways of reinforcing rational thinking and achieving the E include having
clients make rational posters and banners or write rational limericks, in which a
rational concept is embedded into the limerick. For instance, one of my clients and
I made up the following limerick to help her deal with friendship issues:
Once there was a girl named Sue
Who was tired of being so blue
So if no one wanted to play
She just went her own way
And found something better to do.
Other strategies include having clients find examples of rational music, interviewing others about “having” to be perfect, or writing rational coping self-statements
with regard to a particular problem (I want to get a scholarship and I will do my best
to write the required essay, but if I don’t get it, I’m not stupid or unworthy). Having
them respond to their own problem as if they are writing advice to someone else
with that same issue can also be effective.
HOMEWORK
Another way of reinforcing the effective new thoughts, feelings, and behaviors is
through simple homework assignments, which I prefer to call “experiments” with
young clients who often have negative connotation regarding homework. Bibliotherapy and cinematherapy, where the counselor assigns something for the client to
read or watch related to a rational concept that needs to be reinforced, can be very
effective homework assignments. Other homework assignments could be behavioral,
such as suggesting that the client try asking a friend to do something together instead
of waiting for the friend to ask him or her, or study for a test just to see if it makes
a difference. Homework assignments should be creative and engaging to increase
the likelihood that clients will follow through. An effective homework assignment
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that I used with an adolescent is described in the “Voices from the Field” sidebar
on this page.
VOICES FROM THE FIELD—ADOLESCENT
My parents were upset with me because my grades were slipping and I was skipping school so I could be with my boyfriend. They made me go to counseling,
which really ticked me off. I told the counselor I really didn’t have a problem; I
didn’t care about school or going to college, and they were trying to force me to
change. I thought the counselor would side with my parents, but all she said was
that nobody could really make me change. She said that I just needed to be sure
that I was making the right choices. As a homework assignment, she asked me to
take some pictures of how my life would be like in 4 months if I kept getting bad
grades, skipping school, and just hanging out and drinking with my boyfriend.
She also asked me to take pictures of what my life would be like if I decided to
change. I actually liked doing that, and at the next session we talked about the
two sets of pictures. She asked me a lot of challenging questions and I finally realized that I really did want to go to college but just didn’t like studying. Dr. Vernon
helped me see that I didn’t have to like studying, but if I wanted to achieve my
goal, I needed to tolerate it, and it wasn’t like I couldn’t do it if I chose to. I think
counseling helped put me on the right path!
—Saloni, age 17
RATIONAL-EMOTIVE EDUCATION (REE)
As previously noted, Albert Ellis was a long-time proponent of the application of
REBT in educational settings because an integral aspect of REBT is the emphasis
on teaching, prevention, and skill acquisition. Rational-emotive education (REE) is
a social-emotional educational program that helps young people help themselves by
learning the general principles of emotional health and how to apply these principles to help them deal more effectively with the challenges of growing up (Vernon
& Bernard, in press). The importance of teaching rational concepts to school-age
children should not be underestimated because so many problems can be prevented
or lessened in severity. Furthermore, the high incidence of teen suicide, self-harm,
bullying, and school shootings is proof that prevention programs are needed throughout the world in today’s society (DeVoe & Bauer, 2011; Everytown, 2014; Hawton,
Saunders, & O’Connor, 2012).
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The skills-oriented approach, which characterizes REBT and REE, helps children
deal more effectively with the problems in the present as well as in the future. These
“life lessons” better equip young clients to apply cognitive, emotive, and behavioral
strategies to lessen the severity and intensity of problems that can impede their development and their success in life. Through classroom and small group applications,
children and adolescents develop “tools” to help them deal more effectively with typical
developmental problems as well as more serious situational issues. Skill acquisition is
a unique aspect of REBT/REE and makes it particularly applicable for young people
who may be limited in their ability to conceptualize situations accurately, make good
judgments, and understand ramifications of their own and others’ behavior.
There are now a number of best practice school-based programs that address
social-emotional development based on REBT, including Rational Emotive Education (Knaus, 1974), the Thinking, Feeling, Behaving curricula (Vernon, 2006a,
2006b), and Program Achieve (Bernard, 2018a, 2018b). These programs all support
Bernard’s contention (Ellis & Bernard, 2006) that teaching children social and emotional competence is essential not only for their social and emotional well-being,
but also for their academic achievement, success in life, self-management, and sense
of social responsibility.
A very compelling reason to employ REE in a school setting is that a majority of
children and adolescents who receive mental health services only get them in school,
and the number of students needing mental health services is increasing (Perou et al.,
2013). Because of its emphasis on skills acquisition and the fact that an REE program
can increase school achievement makes it a logical choice for a social-emotional
education program that can be implemented in classrooms and small groups.
CLASSROOM APPLICATIONS
The basic premise of REE in a classroom setting is that a systematic, structured
curriculum based on REBT principles can empower young people to take charge of
their lives to the degree that this is possible: learning how to think, feel, and behave
in a self-enhancing rather than self-defeating manner. REBT is uniquely suited for
a prevention program because the principles can be easily transferred into specific
developmentally appropriate lessons (Vernon & Bernard, in press). The concepts
can be adapted to various age groups, ethnicities, and intelligence levels, and there
are numerous cognitive behavioral techniques that can be employed in creative
ways, making it much easier for children to comprehend what it being presented
(Vernon, 2009a).
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In addition, REE reinforces goals compatible with educational goals: critical
thinking skills, problem-solving and decision-making skills, practice and persistence,
self-reliance and self-responsibility, and goal setting, which all promote achievement
(Vernon & Bernard, in press). Implementing REE in schools also increases achievement by teaching specific skills such as frustration tolerance, rational thinking, and
self-acceptance, and by reducing emotional upset, which can interfere with learning
and achievement.
REE Lessons
REE lessons are based on the general principles of REBT, including the basic premise
that unhealthy feelings and self-defeating behaviors are based on irrational thinking.
REE lessons typically include topics such as self-acceptance, feelings, beliefs and
behaviors, and problem solving/decision making. Lessons should be interactive
and experiential, with a good deal of student involvement to increase the likelihood
that students will engage in the activities. REBT concepts are presented through
age-appropriate games, role-play, music and art activities, bibliotherapy, worksheets
and writing activities, and other creative approaches. A critical aspect of these lessons is the debriefing, where students discuss the content of the lesson and how to
apply the concepts to themselves.
I developed a format for REE lessons in the Thinking, Feeling, Behaving curriculums. The lesson begins with a short stimulus activity designed to engage students
and present the basic concepts of the lesson. This activity should relate to the objectives of the lesson and be developmentally and culturally appropriate. The activity,
which should take no more than 20–25 minutes, depending on the amount of time
designated for the lesson, is followed by several content questions, which pertain
to the content of the lesson, and personalization questions, which help students
personalize the information and apply it to their own lives. The discussion of the
content and personalization questions typically lasts 15–20 minutes, depending on
the children’s age and the designated time period. Following is an example of an
REE lesson (adapted from Vernon, 2006a) for second or third graders to help them
learn to differentiate between facts and assumptions.
BE A FACT FINDER
Objective: To learn the difference between facts and assumptions.
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Materials needed: 15 fact cards and 15 assumption cards (or more, depending on
the size of the class), written on index cards, such as:
Fact cards: Yellow is a bright color, the moon is not always full, eating too many
sweets isn’t good for you, exercise helps you stay healthy, corn is a vegetable, etc.
Assumption cards: She doesn’t like me; he’s doing that just to be mean; if you
eat healthy foods you will never get sick; books with lots of pages are better
than those without; and so forth. These cards should be hidden randomly
throughout the room.
Procedure:
1.
Introduce the lesson by holding up a ball and asking students to tell you something about the ball that is based on a fact—something that is true and can be
proven, such as the ball is round, red, etc.
2.
Ask them to make some assumptions about the ball, first explaining that an
assumption is something that may or may not be true; it has to be “checked
out” before it can become a fact. Some assumptions about the ball could be
that it bounces high, it is very firm, etc.
3.
Divide the class into teams of four and give each team member a colored flag
to raise when they find a card (all members of one team have the same color,
but each team has a different color). Then, have each team select a leader and
give each leader a paper bag. Explain that the teams are going to be “fact finders,” which means that each team tries to find as many cards as they can that
are hidden throughout the classroom. When team members find cards, they
hold up their flag and their leader puts that card in his or her bag. During the
time they are hunting for cards there can be no talking. After it appears that
most cards have been picked up, have each team look at their cards and decide
which of them are facts (true) and which are assumptions (beliefs that need to
be proven to be considered a fact).
4.
Ask each team leader to read the cards and identify them as facts or assumptions, engaging students in discussion if they mistake an assumption for a
fact or vice versa.
5.
Debrief the activity by asking the following questions:
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Content Questions:
1.
What is the difference between a fact and an assumption?
2.
If you want to know whether an assumption is true, what can you do?
3.
Why do you think it is important to know the difference between a fact and
an assumption?
4.
What could happen if kids don’t understand the difference between facts
and assumptions?
Personalization Questions:
1.
Have you ever thought that something was a fact but it really was an assumption? What happened when you made that assumption and didn’t check out
the facts?
2.
Has someone ever assumed something about you without checking out the
facts? If so, what were the consequences?
3.
What did you learn from this activity and how will you use this information?
The information learned from the REE lesson can be extended by encouraging
children to be “fact detectives” at home and at school, finding examples of facts
and assumptions and sharing them in class the next day. The teacher can also
reinforce this distinction as situations arise. For example, several days after the
students had participated in the “Be a Fact Finder” lesson, a group of students
returned from recess, arguing vehemently about a situation that had erupted on
the playground. The teacher pulled them aside to discuss the problem and asked
them to think about the facts versus the assumptions related to this incident. It
became clear that while they all agreed on the facts, they had different assumptions, so the teacher helped them clarify the assumptions by checking out the facts.
This “teachable moment” is an excellent way to routinely integrate REE concepts
into the total school environment.
REE emotional education lessons should be implemented regularly with children
at both the primary and secondary levels. The topics should be presented sequentially, with core ideas introduced and reinforced as developmentally appropriate. For
sequentially based REE lessons, refer to Thinking, Feeling, Behaving: An Emotional
Education Curriculum for Children (Vernon, 2006a), Thinking, Feeling Behaving:
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An Emotional Education Curriculum for Adolescents (Vernon 2006b) and Program
Achieve (Bernard, 2018a, 2018b).
SMALL GROUP COUNSELING APPLICATIONS
Ellis (2002) was also a strong proponent of rational-emotive behavior group therapy
(REBGT) and maintained that it can be more effective than individual counseling.
Terjesen and Esposito (2006) claim that a distinctive feature of REBT groups is that
they are more psychoeducational, with the goal being to educate group members about
how to change their dysfunctional thinking to feel and behave differently. Two ways
to incorporate REBT concepts into small group settings include problem-centered
groups and preventive groups (Vernon, 2009a).
Problem-Centered Groups
In the problem-centered group, members discuss their current concerns and the
group leader, with assistance from other group members, introduces REBT principles that help them deal with their issue. This type of group is more appropriate for
middle school and high school students because they are better able to articulate
their problems and understand and apply concepts. A problem-centered group
is more open-ended in that there isn’t a specific theme or topic applicable to all
members. For example, if there are six students in a group, one may be dealing
with parental divorce, another may have problems with friends, and another may
have issues with performance anxiety. The problems vary from week to week,
person to person, and group members not only receive help from the facilitator
and others relative to their problem, but they can help others by offering their
perspectives, clarifying distorted thinking and assumptions, and so forth. Generally speaking, because six to eight members voluntarily join a group of this
nature, there is more discussion and group participation. The group can go on
indefinitely, with members dropping out when they no longer need the group,
which allows others to join.
A variation of the problem-centered group is to select a specific topic that all
group members are dealing with, such as anger, anxiety, depression, frustration
intolerance, perfectionism, or procrastination. This group is suitable for all ages,
and it is generally a volunteer group, although at times the counselor may ask a
client in individual counseling to participate because the topic is relevant to his
or her issues. The focus of these groups is to help group members apply REBT
concepts to specific problems relative to the identified topic. Initially, the leader
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assumes a more active role in presenting rational thinking concepts and other relevant information related to the topic, so there are usually short stimulus activities
that introduce the topic and initiate discussion. Group members are encouraged
to offer insight and help others. A group like this may meet 6 to 10 weeks or until
members no longer need it.
Preventive Groups
Another type of group, the preventive group, is more psychoeducational in nature
and is suitable for all ages. Rather than having a specific problem, group members
join the group to learn more about rational concepts that will help them deal with
future problems. This type of group is similar to a classroom group where the focus
is on prevention, but the advantage is that there are six to eight members, so there
is more emphasis on personalizing the concepts and more opportunity for interaction. These groups are typically 6 to 8 weeks and are centered on a theme, such as
communication and assertion skills, problem solving and decision making, school
achievement, or relationships with parents or peers. REBT concepts are presented
with the idea of teaching skills. A variation is to specifically teach REBT principles
such as self-acceptance, dealing with emotions from an REBT perspective, identifying irrational beliefs and how to dispute them, and so forth.
This type of group is more didactic, but a variety of techniques can be used to
introduce content to make it more meaningful, engaging, and understandable:
role play, games, bibliotherapy or cinematherapy, experiential activities, drama, or
art and music interventions. The activities are designed to stimulate interest and
facilitate understanding of rational principles and develop problem-solving skills.
For example, a group session for fifth graders focused on identifying rational and
irrational beliefs. The group leader introduced the topic by pretending to be a student
with many irrational beliefs. This “student” was studying for a test and said things to
herself such as, “I’m so dumb. Why do I even bother studying? I know I will never
pass the test. I’m such a loser.” Debrief with group members, discussing why these
beliefs are unhelpful and how they could affect a student’s behavior. Then, with the
group members seated in a circle, toss a ball to one of them and read an example of
a rational or irrational belief. This student has to identify if it is a rational belief, and
why, or an irrational belief. If it is irrational, the student tosses the ball to another
student who explains why it is irrational and comes up with a replacement belief
that is more rational. The game proceeds in this manner and debriefing focuses on
the difference between rational and irrational beliefs.
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REBT APPLICATIONS WITH PARENTS AND TEACHERS
According to Hickey and Doyle (2018), “When REBT is used with children and adolescents, the work often extends beyond the identified client to parents and school
personnel” (p. 129). Ellis began applying REBT theory to parenting in the 1960s,
maintaining that parents’ strong negative emotions interfere with their ability to be
effective parents and that these emotions are directly related to irrational beliefs (Vernon
& DiMattia, 2012). Ellis also believed that consultation with teachers and other school
personnel was important to so that they could model rational concepts and work on
their own beliefs that impacted their relationships with children, as well as with colleagues and parents (DiGiuseppe & Kelter, 2006). Although traditional approaches to
teaching and parenting offer practical suggestions for dealing with problems, REBT
goes beyond that, helping adults who live and work with children identify irrational
beliefs that cause unhealthy negative emotions and ineffective behavioral reactions
that interfere with good parenting and teaching (Hickey & Doyle, 2018).
IRRATIONAL BELIEFS OF PARENTS AND TEACHERS
The following irrational beliefs have a significant negative impact on parents’ and
teachers’ emotions and behaviors (Vernon & DiMattia, 2012).
•
Self-downing—Despite the fact that most parents receive no instruction or
training about how to be a good parent, they still expect themselves to be
perfect and think that if their children have problems, it is their fault—they
did something wrong. Parents who engage in self-downing equate their selfworth as a parent with their child’s performance, thinking that if their children
perform poorly, they are terrible parents. Teachers also engage in self-downing,
thinking they have to be perfect teachers and that if children have problems
in the classroom or don’t perform well, they are inadequate. From a rational
perspective, parents and teachers need to remember that they do the best they
can, but they are not the sole influence in childrens’ lives and they can’t control
every aspect of their behavior.
•
Demanding—Demanding parents and teachers expect children to behave perfectly at all times. When this doesn’t happen, they often get angry, which in
turn results in aggressive punishment instead of effective discipline. Rather than
making rigid demands, parents and teachers should accept the reality that all
children misbehave to some extent some of the time and reduce their demandingness so that they can employ developmentally appropriate discipline strategies.
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•
Frustration intolerance/discomfort anxiety—Parenting isn’t easy, and neither is
teaching, but parents and educators with frustration intolerance think that it
should be easy, and they have little tolerance for any of the challenges or hassles
that naturally occur with children. In addition, they think that they themselves
cannot stand to be uncomfortable and they avoid dealing with problems because
they don’t want the conflict. Parents in particular may not want their children
to experience any discomfort so when they complain about having to get up
early to deliver the newspapers, the parents do it for them, thus reinforcing the
idea that children shouldn’t have to do things that are too difficult.
•
Awfulizing/catastrophizing—Parents who awfulize blow things out of proportion and magnify the significance of something. For example, they may think
it is the end of the world if their children don’t keep their rooms clean or if
they pierce their ears or dye their hair. It is important for parents to put things
in perspective. Teachers as well may exaggerate the importance of something,
which can result in strong negative reactions toward the child.
When parents and teachers adhere to one or more of these irrational beliefs, it
interferes with their ability to be effective at parenting or teaching. Counselors who
consult with them need to help them understand that they are fallible human beings
who should try their best, but inevitably they will make mistakes because children
are unique individuals with different temperaments who, unfortunately, don’t come
with a set of operating instructions (Vernon & DiMattia, 2012). Read about how a
teacher benefitted from REBT in the “Voices From the Field” sidebar.
VOICES FROM THE FIELD—PROFESSIONAL
When the counselor in my school introduced the faculty to REBT, I could definitely see the benefits of a social-emotional curriculum for children based on REBT
concepts, but I also liked the way I could use it to help me with my own problems.
It was particularly beneficial to learn that the way I think affects the way I feel, and
when I started applying this to some of the issues I had with certain colleagues
and parents, I understood that while I couldn’t change the things they did that
irritated or upset me, I didn’t have to let them get to me. Now I believe that
thinking rationally helps reduce my stress. I would advise readers of this chapter
to use REBT principles on yourselves!
—Beverly, third-grade teacher
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TEACHING AND PARENTING STYLES
Parents and teachers also need to learn how their parenting or teaching styles affect
children and adolescents. Consider the following:
Authoritarian Style
Demanding parents and teachers adopt an authoritarian style, believing that getting
angry is an effective way to modify children’s behavior. They also think that children
should never misbehave or disagree with them. Authoritarian parents and teachers
have very rigid rules and are punitive in their approach to discipline. Children raised
by or taught by authoritarian parents raise children who are fearful and anxious, as
well as resentful. True, they may be well-behaved, but is it worth the price? (Vernon
& DiMattia, 2012).
Permissive Style
Parents and teachers with frustration intolerance or discomfort anxiety usually
adopt a permissive style (Vernon & DiMattia, 2012). They care about children but
they can’t stand conflict, so they think it is easier to give in and let children do what
they want. These parents generally have few rules, but if they do have rules, they are
inconsistent and unclear. The same applies for the classroom teacher. Parents and
teachers who practice the permissive style think that discipline is wrong and it is
too much work to follow through. Children who live in permissive homes or have
permissive teachers know that if they misbehave, their behavior will be overlooked.
They soon learn that threats of consequences are just that—threats—and that if they
are punished, it won’t last long. While it may seem like adolescents in particular
like the permissive style, in reality, they often get anxious if parents and teachers
are too permissive and inconsistent or if rules and consequences aren’t clear. These
children do not develop self-control or learn to take responsibility for their actions.
Authoritative Style
This is the preferred style of parenting and teaching, and children who experience
this style are self-reliant, perform better in school, have higher self-esteem, and are
less likely to be rebellious (Vernon & DiMattia, 2012). Authoritive parents and teachers
are firm but caring; they have reasonable rules and consequences. These parents and
teachers are considerate, firm but caring, and believe in collaboration and communication. They have clear expectations and discuss behavior with children, helping them
develop tolerance for the inevitable frustrations they will experience throughout life.
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TAKE-AWAYS FROM CHAPTER 7
As I conclude this chapter, I want to refer to the vignette at the beginning of the
chapter and share what I learned from working with this client, as well as a technique
that I used, which I think was effective. What I learned from working with Mrs.
Chang is that I was too eager to solve the practical problem, which was to reduce her
stress, without working on the emotional problem, her guilt. In all honesty, initially
I was not very effective with this client because I didn’t address her beliefs about
being a good parent, which resulted in her guilt. But after reading more about REBT,
I used logical disputing: “Is it logical to think that if your children don’t perform
well in their recital that you are a failure as a mother?” “Does it really make sense
to think that you are totally responsible for your children’s performance?” I also
used the “best friend” technique: “If you best friend came to you and said she was
a horrible mother because her child got a bad grade on his science project, would
you agree with her?” This approach was much more effective, and after disputing
her irrational beliefs, she began to change her behavior by rotating help with the
piano and school work, thus reducing her stress.
After reading this chapter, you now should be more knowledgeable about these
key points:
•
The rationale for using REBT with children and adolescents
•
The basic principles and practices of REBT
•
How to apply the A-B-C model with children and adolescents
•
How to use the C.A.T. model to connect with young clients; assess the activating event, beliefs, feelings, and behaviors; and treat the problem by teaching
rational thinking
•
Specific disputing techniques applicable for young clients
•
Examples of cognitive, emotive, and behavioral interventions
•
Small group and classroom applications
•
Applications with parents and teachers, including teaching and parenting
styles and irrational beliefs
HELPFUL WEBSITES
www.albertellis.org
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Albert Ellis Institute, On Demand Pages—
http://vimeo.com/user38239091/vod_pages
PRACTICAL RESOURCES
*Carlson, N. (1992). What if it never stops raining? New York, NY:
Penguin Books.
Ellis, A. E., & Wilde, J. (2002). Case studies in rational emotive behavior
therapy with children and adolescents. Upper Saddle River, NJ: Merrill
Prentice Hall.
*Mitchell, B. K. (2009). Tiger-tiger, is it true? Carlsbad, CA: Hay House.
*Scieszka, J. (1989). The true story of the three little pigs. New York, NY:
Scholastic.
*These three books are excellent REBT-based children’s stories that can also be used with adolescents to make
a point about rational thinking, perspective taking, and awfulizing.
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Bernard & W. Dryden (Eds.), Rational emotive behavior education in schools. New York,
NY: Springer.
Vernon, A., & DiMattia, D. (2012). Helping couples deal with parenting and grandparenting. In A. Vernon (Ed.), Cognitive and rational-emotive behavior therapy with couples:
Theory and practice (pp. 225–241). New York, NY: Springer.
Waters, V. (1981). The living school. RET Work, 1, 1–6.
Waters, V. (1982). Therapies for children: Rational-emotive therapy. In C. R. Reynolds &
T. B. Gutkin (Eds.), Handbook of school psychology (pp. 37–57). New York, NY: Wiley.
Wilde, J. (1992). Rational counseling with school-aged populations: A practical guide. Bristol,
PA: Accelerated Development.
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CHAPTER 8
Counseling Children and Adolescents
With Exceptionalities
Tori Stone and Pamelia E. Brott
LEARNING OBJECTIVES
1.
To extend understanding of the categories of exceptionality that may apply to
children and adolescents
2.
To expand knowledge of how exceptionality may affect children and adolescents as they progress through developmental stages
3.
To increase understanding of interventions that can be used when counseling
children and adolescents with exceptionalities
T
im, an 11-year-old child with mild autism, rips off his shirt (and sometimes
other clothing) when he is frustrated in class. When his instructional assistant
tells him he must keep his shirt on at school, Tim’s frustration is exacerbated,
and he yells, hits others, and runs out of the classroom and down the hallway half
dressed. When Tim was brought to my (Tori) office after one such outburst, I did
everything I could to make the environment hospitable for him. I did not mention the
missing shirt, but instead turned off the bright overhead lights in my office (stimulus)
and left on a small lamp. Then I said, “Tim, I notice that you’ve taken off your shirt,
so you must be hot. Let me turn on the fan.” I gave Tim some Kinect Sand (manipulative medium) to play with while he sat in the beanbag chair (preferential seating)
on the floor. “Let me know when you are ready to talk” I said as I began to work
quietly at my desk. About 10 minutes later, Tim had put his shirt back on and asked
to go back to class. I said I would allow him to return to class, but I wanted to make
sure the same situation wouldn’t happen again. So, I told him we needed a new plan
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that would help him when he felt hot, overwhelmed, or overstimulated. Tim and I
developed a feelings thermometer (Vernon, 2006) to help him identify when he feels
“cool,” fine and able to stay in class; “warm,” getting overwhelmed or overstimulated
and needing a break in the chill out area of the classroom; or “hot,” needing to leave
the room and cool down with adult support. I spoke with Tim’s teacher, instructional
assistant, and parents about the feelings thermometer and e-mailed a copy of it so
that we all could use the same language to help Tim in times of distress.
As this vignette illustrates, children and adolescents with exceptionalities may
communicate through overt behaviors that they are not coping. Our best first step
is to provide a quiet, calm environment where they can de-escalate, de-stress, and
re-focus. Parents and other professionals need to be part of a team that maintains
structure, routine, and consistency so exceptional children and adolescents have the
best possible opportunity to thrive in both school and home settings.
The purpose of this chapter is to provide an understanding of exceptionality and
recommended counseling approaches for school and mental health counselors. It is
imperative that counselors consider development, the environment, and the associated
features of the student’s disability when making educational and clinical decisions. We
begin with a brief introduction to exceptionality, followed by categories of disability, as
defined by federal legislation, as well as developmental features of children and adolescents with respect to specific learning disabilities such as attention-deficit/hyperactivity
disorder, autism spectrum disorder, and emotional disturbance. Giftedness in children
and adolescents completes the section on descriptions of exceptionality. The second
half of the chapter addresses counseling interventions for youth with exceptionalities.
INTRODUCTION TO EXCEPTIONALITY
As the case of Tim illustrates, children with exceptionalities show greater variance in
their abilities either above or below what is expected developmentally. These children
may exhibit challenges in learning and/or behavior that preclude them from fulfilling
their potential. Exceptionality is an inclusive term used to embrace students who have
learning and/or behavioral problems, physical disabilities or sensory impairments, or
who are gifted or have a special talent. In some cases, the child may be twice exceptional, referring to having both a disability and a gifted or special talent.
Children and adolescents may be referred for evaluation of their abilities “to
inform diagnostic impressions and to guide educational planning and programming” (Wexler, 2017, p. 1). Considerations of a medical condition, treatment that
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may include medication(s), and functioning in the school and home environments
provide a more comprehensive assessment of the child. School evaluations are used
to determine eligibility for special education services through an individualized
educational program (IEP) (IDEA, 2004). Collaboration and consultation between
parents and professionals, such as doctors, psychologists, counselors, and teachers,
provide the best opportunity for children with exceptionalities to succeed in both
home and school environments, according to Wexler. Recognizing and addressing the
contextual considerations for these children, which includes disproportionality, is vital
to providing appropriate educational experiences to prepare them for their futures.
Disproportionate representation of racial, ethnic, linguistic, and socioeconomic
status (SES) groups in special education and related services occurs when significant
numbers vary from the general population. An integrative synthesis of literature
on disproportionality in special education found that “race is a strong predictor
of disproportionality in identification for special education” (Cruz & Rodl, 2018,
p. 58). African American students were overrepresented in emotional disability and
intellectual disability, Asian students were underrepresented across all disability
categories, results for Latino students were mixed, and students from lower SES
were more likely to be identified for special education. Linguistic disproportionality research points to mixed results for English learners (Counts, Katsiyannis, &
Whitford, 2018). Variances by state, changes in disability definitions over time, and
variety of datasets point to the complex nature of disproportionality (Cruz & Rodl).
Over- and under-representation results in students being misidentified; not receiving
needed services; and being unfairly suspended, expelled, or separated from their
peers (U.S. Department of Education, 2018). Therefore, race, culture, linguistics,
and SES should be taken into consideration when screening and referring children
for special education evaluation (Samson & Lesaux, 2009; Sullivan & Bal, 2013).
STUDENTS WITH DISABILITIES IN SCHOOLS
The Individuals with Disabilities Education Act (IDEA, 2004) ensures that all children with disabilities have access to a “free appropriate public education” (FAPE) that
meets their unique needs and prepares them for future education, employment, and
independent living. The law protects the rights of children with disabilities and their
parents and helps local education entities to implement a comprehensive, coordinated,
multidisciplinary, and interagency system for early intervention and effective efforts
to educate children. Child Find is a screening process required by IDEA to identify
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children with disabilities or those who may be at risk for developing a disability and
need special education and related services (IDEA, 2004, Part B, Subpart B, Sec.
300.111).
A collaborative team comprised of school personnel, families, and community
members partner to provide support and services to help students succeed. The
collaborative team plays a vital role in participating in the Child Find process and
advocating for the needs of children and adolescents with exceptionalities. The team
identifies students’ needs, then secures and connects resources to meet those needs so
that children have opportunities to be successful, both personally and academically.
A strength of a team approach is that no one person is making a decision, particularly
for special education students. A key team player is the school counselor who, at a
minimum, has earned a master’s degree and has specialized training in organizing
and delivering a comprehensive, developmental school counseling program.
An individualized educational program (IEP) ensures that a child with a disability
who is attending an elementary or secondary school receives specialized instruction and
resources (IDEA, 2004, Part B, Subpart B, Sec. 300.112). The IEP is developed to reflect
the child’s strengths; parental concerns; results of the child’s most recent evaluation; and
academic, developmental, and functional needs of the child (IDEA, 2004, Subchapter
II, 1414, d.3). Related services offered to students with disabilities include psychological services; counseling services provided by qualified social workers, psychologists,
school or mental health counselors, or other qualified personnel (IDEA, 2004, Sec.
300.34, c.2); and parent counseling and training. Counseling services included in the
IEP must be documented with measurable results and are reviewed yearly.
The Rehabilitation Act of 1973, Section 504, protects the rights of students with
disabilities to have access to programs and activities that receive federal financial
assistance. Section 504 regulations require a school district to provide a “free appropriate public education” (FAPE) to each qualified student with a disability who is in
the school district’s jurisdiction, regardless of the nature or severity of the disability
(U.S. Department of Education, 2018). Referrals can be made by parents or school
personnel when they suspect that the student will require an accommodation because
of a disability or impairment. Eligibility is determined through a variety of records
and sources, such as parent and teacher narratives and observations, counselor
reports, student’s physical condition and health information, and informal and
formal classroom assessments. The 504 plan ensures that formal accommodations
are made to allow the student opportunities to participate in or benefit from the
school’s programs and activities.
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In the school setting, a multi-tiered system of support (MTSS) is a framework
aimed at systematically supporting students, particularly those with learning and
behavioral problems, through differentiated support “to improve academic, behavioral, and socio-emotional outcomes of all students” (Wexler, 2017, p. 3). MTSS
fosters a positive school climate through an inclusive schoolwide approach and then
targets groups of students and/or individual students for differentiated interventions.
MTSS is grounded in differentiated instruction, which recognizes that students have
individualized learning styles and needs. It is a three-tiered system, with each tier
targeting different types of services and supports with increasing intensity from tier
1 (primary; whole group) to tier 2 (secondary; supplemental time, exposure, and
practice), to tier 3 (tertiary; intensive support from specialized personnel). MTSS
includes response to intervention (RTI) (National Center on Response to Intervention, 2010) and Positive Behavioral Interventions and Supports (PBIS, 2018). Some
use the terms MTSS and RTI interchangeably; however, MTSS is the umbrella term
that includes both RTI and PBIS.
RTI uses the three-tiered system as levels of intervention: all students (tier 1),
small groups of students (tier 2), and individual students (tier 3). Interventions
of increasing intensity are matched to the tiers, with a focus on helping students
improve in problem areas by monitoring progress. The purpose of PBIS is to
reinforce appropriate behaviors and decrease/prevent inappropriate behaviors.
It is a problem-solving framework used with students based on a demonstrated
level of need.
UNDERSTANDING EXCEPTIONALITY
Categories of disability, as defined by the Individuals with Disabilities Education
Act (IDEA, 2004), include the following: specific learning disabilities, speech and
language impairments, other health impairment, autism, intellectual disability,
developmental delay, emotional disturbance, multiple disabilities, hearing impairment, visual impairment, traumatic brain injury, and orthopedic impairments.
Although not included as a category defined by IDEA, giftedness is an important
exceptionality for counseling practitioners to understand. For the purposes of this
chapter, the focus will be on specific learning disabilities, other health impairments
(i.e., attention-deficit/hyperactivity disorder), autism spectrum disorder, emotional
disturbance, and giftedness. The following sections provide an overview for these
exceptionalities, as well as suggested interventions.
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SPECIFIC LEARNING DISABILITIES (LD)
A specific learning disability is a disorder in one or more of the basic psychological
processes involved in understanding or using spoken or written language that manifests itself through difficulty in listening, thinking, speaking, reading, writing, or
performing mathematical calculations (National Institutes of Health (NIH), 2016b).
According to the National Center for Education Statistics (NCES), in 2014–15, 35% of
all children and youth receiving special education services had specific learning disabilities (NCES, 2017). Children and youth ages three to 21 years old received special
education services under IDEA for specific learning disabilities more than for any other
type of disability (NCES, 2017). The American Psychiatric Association (APA, 2013)
reports the prevalence of learning disorders is about 5% to 15% of school-aged children.
Developmental Features of Children With Specific Learning Disabilities
Children and adolescents with learning disabilities experience persistent difficulties
in learning essential keystone academic skills (e.g., reading accuracy, fluency, and
comprehension; math calculation and reasoning). These learning difficulties can affect
children’s ability to succeed in academic areas outside of the disability. Preschool
children with learning disabilities frequently show an uneven profile of abilities. For
example, they may demonstrate strengths in some areas (e.g., art, design) as well as
delays in attention, language, and motor skills (APA, 2013).
Elementary school children diagnosed with a specific learning disability may have
difficulty with the academic tasks such as reading fluency, decoding, spelling, and/
or math. They may struggle to listen well, stay on task, and succeed in social situations (NIH, 2016b). Middle school children with learning disorders may continue
to struggle with increasingly difficult academic tasks in math and reading and may
have trouble remembering dates, homework assignments, and completing and turning in schoolwork on time (APA, 2013). These academic and social difficulties can
negatively affect self-esteem and leave children feeling as though they are not good
at anything. For this reason, it is important for counselors to emphasize a strengthsbased approach with a focus on cultivating a growth mind-set (Dweck, 2016). Growth
mind-set encourages children to work through their learning differences to find
success. You can read more about this in chapter 10.
Teenagers with learning disabilities who have not received appropriate academic
supports are at higher risk of using tobacco, alcohol, and drugs. Dropping out of
school is related to functional illiteracy, and teens who drop out are at risk of getting
involved in illegal activities, being incarcerated, and becoming teen mothers and
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fathers (Learning Disabilities Association of America, 2018b). It is imperative that
counselors work closely with adolescents with learning disabilities and help them
understand the challenges they may face with this disorder. Counselors can reduce
their anxiety by educating them about their learning disorder and how it can impact
their functioning, both socially and academically. It is especially important for counselors to support them and help them learn specific coping skills (Cummings, 2016).
Older adolescents and adults with learning disorders may continue to have difficulty in spelling, reading fluency, and math computation. Because of these difficulties,
they may avoid activities that require academic skills (APA, 2013). They may also
have awkward social skills due to related deficits in perception, including misreading
facial expressions, body language, or verbal cues, which can lead to poor self-esteem
(Learning Disabilities Association of America, 2018b). Functional consequences
of learning disorders include lower academic attainment, higher levels of psychological distress such as anxiety and depression, or higher rates of unemployment/
under-employment that can result in lower income (APA, 2013).
It is also important to remember that parents also are affected when their children
have a learning disability. Counselors can offer groups for parents to help them
manage their stress and provide support and techniques for helping their child with
organization, study skills, and so forth. Take a moment to read the “Voices From
the Field” sidebar describing a parent’s struggle with her son’s experience in school.
VOICES FROM THE FIELD—PARENT
Brian was an active kid, leaping over couches, climbing trees, etc. As a therapist and
school counselor, I knew school would be difficult for him—lots of rules and sitting
still. I was not surprised when he was diagnosed with ADHD and a learning disability. Learning to read is not easy for kids with ADHD; after all, maintaining focused attention is part of the disorder; they can skip words and whole lines of text, and their
high level of distractibility makes it easy for them to lose their place, lowering both
fluency and comprehension skills. In spite of the special education supports provided by the school, Brian struggled to learn to read. I remember one day when he
was 8 years old he told me he wanted to kill himself because he couldn’t read. I was
terrified, heartbroken, and desperate to find him help. We found a targeted reading program at a local university and he went there several days a week that whole
summer as well as the following summer. Thankfully, things improved dramatically.
–Elizabeth, parent of child with a learning disability, retired
therapist, and school counselor
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Interventions for Students with LD
Children with learning disabilities require additional support from school staff and
counseling professionals. The following sections provide an overview of interventions
for children and adolescents diagnosed with LD.
Counseling
Children and adolescents with learning disabilities can benefit from individual and
small group counseling services. Strength-based counseling services focused on
building self-esteem and teaching coping skills to deal with the frustration, anger,
and anxiety associated with the learning disorder can help. Solution-focused counseling, rational-emotive and cognitive behavior therapy, and social skills groups
can also be beneficial to help these youth understand and cope with the challenges
associated with learning disabilities (Patino, 2014).
Organizational Support
Children and adolescents with LD need support to organize their ideas as well
as their personal belongings. They often think and learn visually, meaning that
they understand and remember information better when concepts are presented
through images, graphs, and other visuals aids. Graphic organizers can help
them visualize ideas, organize information, plan writing, brainstorm, organize
problems, compare and contrast ideas, and show cause and effect, for example.
Other accommodations that can benefit LD youth in schools include providing
written copies of class notes, reading tests aloud, taking tests in a small group,
and extending time to complete assignments and tests (Learning Disabilities
Association of America, 2018a).
Postsecondary Planning
Counselors can support students diagnosed with learning disabilities by working
closely with them on postsecondary planning. Researchers have found that when
students with learning disabilities plan for transitions by engaging in activities that
boost their knowledge of postsecondary options, they make significant gains (Milsom,
Akos, & Thompson, 2004; Milsom & Dietz, 2009). School personnel also can offer
informational workshops for students and their families to address postsecondary
transition issues for students with disabilities (Milsom & Dietz, 2009).
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OTHER HEALTH IMPAIRMENT (OHI)
Other health impairment (OHI) refers to having limited strength, vitality, alertness,
or a heightened alertness to environmental stimuli that results in limited alertness
in the educational environment. These impairments may be due to chronic or acute
health problems, such as asthma, attention deficit disorder (ADD) or attention deficit
hyperactivity disorder (ADHD), diabetes, epilepsy, a heart condition, hemophilia,
lead poisoning, leukemia, nephritis, rheumatic fever, sickle cell anemia, or Tourette
syndrome. These other health impairments adversely affect a child’s educational
performance (National Dissemination Center for Children with Disabilities, 2012).
For the purpose of this chapter, the other health impairment that will be addressed
is attention-deficit/hyperactivity disorder (ADHD).
Attention-Deficit/Hyperactivity Disorder
Attention-deficit/hyperactivity disorder (ADHD) is a brain disorder characterized
by a persistent pattern of inattention and/or hyperactivity impulsivity that can
interfere with daily functioning and/or development (NIH, 2016c). According to the
American Psychiatric Association (2013), ADHD occurs in about 5% of children
and 2.5% of adults. Symptoms of inattention include off-task behaviors, difficulty
listening and following directions, lack of follow-through, difficulty sustaining
focus, forgetfulness, and disorganization that is not due to insubordination or lack of
comprehension. Symptoms of hyperactivity include constant motion (e.g., fidgeting,
tapping, getting out of seat) irrespective of the appropriateness of the behavior in
a given situation, excessive talking, and difficulty engaging in quiet play or leisure
activities. Symptoms of impulsivity include actions that occur in the moment to get
immediate results or because of an inability to delay gratification. These actions
occur without forethought and have the potential to be harmful. Impulsive children
may be socially intrusive and have difficulty waiting their turn (e.g., blurting out
responses, cutting in line) and may frequently interrupt others. These behaviors may
result in academic and social problems in childhood and adolescence (APA, 2013).
Developmental Features of Children With ADHD
ADHD symptoms can appear between the ages of 3 and 6 and continue through
adolescence into adulthood. Symptoms are often mistaken for emotional or behavioral
problems or may be missed altogether in quiet, well-behaved children, leading to
a delay in diagnosis (NIH, 2016c). ADHD can affect children in all aspects of their
lives: behavior, learning, social relationships, decision making, and future planning
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(Auger, 2011). In young children with ADHD, hyperactivity impulsivity is the primary symptom. As they reach elementary school, inattention may become more
pronounced and lead to reduced academic performance (APA, 2013). In adolescence,
physical hyperactivity may be replaced by manifestations of restlessness, fidgeting,
and/or impatience, although inattention and impulsivity may remain (NIH).
ADHD affects emotion regulation, causing children and teens with ADHD to have
greater emotional responses and a lower tolerance with frustration than their nonADHD peers (Barkley, 2006). Many children and adolescents with ADHD struggle
with relationships due to impulsive behaviors performed without thinking about
the consequences to self and others. Peers often complain that students with ADHD
are annoying in the classroom because they call out answers, tap pencils, and invade
the personal space of others. Furthermore, they often miss social cues meant to warn
them that their peers are tiring of their behavior. When a classmate has “had it”
with the disruptive behavior and responds angrily, the child or adolescent with ADHD
is often surprised and confused by the outburst. Social skills training, particularly in
group work, can be beneficial to help children with ADHD recognize the negative
consequences of their behaviors and how to develop more appropriate social skills.
Adolescent drivers with ADHD are more likely than their non-ADHD peers to be
involved in traffic accidents and violations due to both impulsivity and inattention (APA,
2013). ADHD makes it difficult for adolescents to organize and regulate their behavior,
which can lead to reduced school performance, academic attainment, and poorer work
performance throughout the lifetime (Auger, 2011). There is also an elevated risk for the
development of a conduct disorder, which may increase the risk for substance abuse and
incarceration (APA). The combination of medication and counseling can help children
and adolescents with ADHD achieve higher levels of academic and social success.
Case Illustration: Alejandro
Alejandro, a 9-year-old third grader with an ADHD diagnosis, was new to our
school. He was brought to my (Tori) attention after his first day of class by his classroom teacher, Mrs. Ash, who was clearly frustrated with him. She said that in one
day, Alejandro had changed the entire dynamic of her classroom, that other children were not responding well to him, and she was worried about her classroom
and his ability to make friends given his inappropriate and annoying behavior.
After Mrs. Ash left, I pulled Alejandro’s file to see if he had received any special education accommodations or supports at his old school. While there was no
evidence of a child study plan or individualized education plan (IEP), I did find a
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thick stack of discipline referrals for talking out of turn, leaving his chair, and disrespecting people and property. The next day, I called Alejandro’s former elementary school counselor who indicated that she had spent a lot of time working with
Alejandro on self-control, but to no avail. She shared that the classroom teacher
and principal had handled many of his behavioral concerns with punishment.
The next call I placed was to Alejandro’s mother, sharing Mrs. Ash’s concerns
regarding a smooth transition and asking if she would be willing to meet with the intervention team to make a plan to ensure Alejandro’s success. Mom agreed, and we
scheduled a meeting for the following week. In the meantime, I met with Alejandro
to explore his feelings about school. Understandably, he said he really did not enjoy
school and felt as though he could never do anything right. He told me that he used
to take medicine for his “wiggles,” but that he had run out some time ago and his
mom had not refilled the prescription. Using a solution-focused approach, I asked
what kind of things he was doing on his very best days at school. He told me his
best days were those when he had taken his medicine, because that made it easier
to stay in his seat. On those days, the teacher did not yell at him, other kids played
with him at recess, and he had fun. I followed up with Alejandro on the things he
was actively doing on the best days, saying, “You are doing some things right on
those days; let’s think about what they are … .” Alexandro thought for some time
and then said, “On the best days I can remind myself to do the things the teacher
and counselor have told me to do to stay out of trouble; on the bad days, I can’t
even think about those things and I am in trouble before I know it.” I showed Alejandro a traffic light as he was discussing his behavior and made sure he understood
what the red, yellow, and green lights were telling motorists to do. “On the good
days, when you are on green, you can tell when you are approaching yellow (time
to slow down), and you can get yourself back together before you hit red (trouble).”
Alejandro seemed to understand this concept and I suggested that he make a little
traffic light that he could put on his desk as a reminder. He said he said he would do
that and he also planned to talk to his mom about going back on his medication. I
encouraged him to do that if he thought it was a good idea.
At the meeting with Alejandro’s mom, we discussed other strategies to support his success at school. Mom shared that she had made an appointment with a
doctor for consultation about medication. Mrs. Ash reported that the traffic light
was helping on some days, and she would often just tap the yellow light to remind
Alejandro to self-regulate. She had also moved Alexandro’s seat to a quiet corner
of the room and had made a rectangle around his desk with tape so that he could
move within the rectangle when he needed to get some wiggles out. As a team,
we also discussed changing Alejandro’s chair to a pedal desk so that he could get
some movement in class, and the principal agreed to purchase one. I agreed to
take Alejandro for a walk, when possible, to expend some energy. The team made
a plan to reconvene in 6 weeks to review progress, and by that time things with
Alejandro had improved considerably.
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This case illustrates the importance of a collaborative approach to address the
needs of young clients such as Alejandro. Various stakeholders were involved in
implementing the interventions identified by the team. In the “Voices From the
Field” sidebar, read about a veteran school counselor’s perspective on working with
children who have been diagnosed with ADHD.
VOICES FROM THE FIELD—PROFESSIONAL
When working with kids with ADHD, it is important to educate the adults around
the children about the disorder. ADHD is about executive functioning—impulse
control, emotion regulation, flexible thinking, monitoring themselves, planning,
getting started on tasks—it affects a lot of systems that are needed for kids to
be successful. As a school counselor, I see so many kids with an ADHD diagnosis
who are down on themselves and who hate school; they don’t feel like they can
be successful. Those same kids have some amazing strengths, they have great
energy, they are creative, they are fun to be around. As educators, we need to
make school more tolerable for these kids; we need to better understand and
accommodate for this disorder. Flexible seating, giving kids a chance to use a
standing desk or to sit on a yoga ball they can bounce around a bit on can really
help. I’ve worked with some great teachers who put little area rugs around kid’s
desks and tell them they can move anywhere in their rug area as long as they are
paying attention and not bothering others. Pedal desks can be great for all kids,
not just kids with an ADHD diagnosis. We can put planned breaks into the school
day for kids with ADHD, which helps them work out their wiggles and return to
class ready to learn. Kids learn through play—they want to move, touch, explore
and discover the world around them. We need think developmentally and set up
schools so that all kids can express their natural learning styles.
—Jennifer, school counselor
Interventions for Children and Adolescents With ADHD
Children and adolescents with ADHD require structure, support, and understanding from their parents, families, and teachers to succeed. Counseling professionals
can provide support by educating parents and other stakeholders about ADHD and
how it can affect a family and a classroom. They also can help the child and parents
develop new routines, skills, attitudes, and ways of intervening to foster a healthy
home environment (Auger, 2011; NIMH, 2016a). The following sections provide an
overview of interventions for ADHD, including medication and counseling.
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Medication
For some children and adolescents, ADHD medications can help to reduce hyperactivity and impulsivity and improve focus and attention that can support learning
and academic achievement. There are two main types of medication that are used to
treat ADHD in young people: stimulants and non-stimulants. Stimulant medications
(e.g., Ritalin, Adderall, Vyvanse) are those most commonly used to treat ADHD,
and they work by increasing the brain chemicals dopamine and norepinephrine,
which play important roles in thinking and attention (National Institute of Mental
Health [NIMH], 2016a). Non-stimulant medications (e.g., Strattera, Intuniv) also
are used to treat ADHD when stimulant medications have caused side effects or
were ineffective. They can also improve focus, attention, and impulsivity but may
take longer to start working than stimulant medications (NIMH, 2016a). Young
clients who are taking medication to treat ADHD must be closely monitored by
their prescribing physician.
Counseling
Children, adolescents, and their family members can benefit from counseling to
provide support, guidance, and resources to treat ADHD and to help children and
their families cope more effectively with everyday concerns. Behavior therapy is often
used to treat ADHD because it can provide practical assistance with behavior modification (e.g., organization, time management, work completion), self-monitoring,
and emotion regulation (e.g., anger management, relaxation techniques). Parent
education is an important component of behavior therapy. Parents are taught to
use a behavior modification system to give immediate positive feedback to their
children for behaviors they want to encourage and to ignore or redirect behaviors
that they want to discourage (NIMH, 2016a).
The following interventions can be beneficial for children and adolescents diagnosed with ADHD (Auger, 2011):
•
Routine, structure, consistency, and clear expectations for behavior
•
Opportunities for movement in the classroom and outlets for high activity
at home
•
Help with organization and time management, including frequent reminders
regarding timelines and expectations
•
Chunking or breaking lengthy tasks into manageable bites
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•
Stress management, social skills training, and relaxation techniques
•
Support groups for children, adolescents, and parents
AUTISM SPECTRUM DISORDER (ASD)
Autism Spectrum Disorder (ASD) is a developmental disability that can result in
significant delays and developmental differences in a number of areas including
communication, social interaction, and behavior (APA, 2013). Children diagnosed
with ASD experience persistent deficits in social communication and interaction
that include difficulty with reciprocal social communication, verbal interaction,
and nonverbal communication (APA; Lemcke, Juhl, Parner, Lauristen, & Thorsen,
2013). Children with an ASD diagnosis may experience difficulty maintaining and
understanding social relationships, ranging on a continuum from sharing in imaginative play or making friends to the complete absence of interest in interacting
with peers. Other characteristics often associated with ASD are repetitive behaviors
and stereotyped movements (e.g., rocking back and forth, flapping arms against
body), resistance to environmental change or inflexible adherence to routines (e.g.,
becoming upset when the routine is changed), fixed interests that are abnormal in
intensity or focus (e.g., intense interest in spinning the wheels on cars, a fixation on
facts about dinosaurs or other topics), and unusual responses to sensory stimuli,
such as yelling when there is a fire drill (APA, 2013).
Developmental Features of Children With ASD
Deficits in social and emotional reciprocity are highly evident in young children
with Autism Spectrum Disorder (APA, 2013). By elementary school, the social,
language, and behavioral deficits of children with ASD are significantly different
from their typically developing classmates and are generally apparent to both
teachers and parents (Auger, 2013). For example, while neurotypical developing
children spontaneously share their discovery of the world with significant adults
and their peers, children with ASD may simply label items or talk excessively
about an interest (e.g., dinosaurs, trucks), regardless of the level of engagement
by their peers (APA). This behavior can be irritating and off putting to other children who may ridicule or socially isolate the child with ASD (Goodman-Scott &
Carlisle, 2018; Sreckovic, Brunsting, & Able, 2014). The “Dialogue Box” sidebar
might help you understand how some children feel about their peers who are
diagnosed with ASD.
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DIALOGUE BOX
This dialogue illustrates the difficulties with social interaction that
children on the Autism spectrum may face. As I (Tori) was dropping
my 8-year-old son, Crosby, at school recently, we saw a former classmate in the school parking lot.
TORI: Do you ever play with Eli anymore?
CROSBY: No Mom, I never play with him.
TORI: Why not?
CROSBY: He is really annoying. All he ever talks about are dinosaurs,
ALL THE TIME! You can’t get a word in about anything else—I don’t
really care about dinosaurs; nobody does anymore.
As children with ASD enter adolescence, difficulties with anxiety, organization,
social communication, and emotional expression present both academic and
social challenges (Auger, 2013). They have deficits in executive functioning (e.g.,
impulse control, emotion regulation, self-monitoring, planning, organization).
Anxiety is a common comorbid condition that co-occurs with ASD (APA, 2013)
that, when coupled with the deficits in executive functioning, often results in
performance anxiety and impedes test-taking abilities (Songlee, Miller, Tincani,
Sileo, & Perkins, 2008). Changes or disruptions in routines can be stressful and
provoke anxiety. Even pleasant events, such as a surprise trip to the beach, can
cause distress because their routine is disrupted (Ozsivadjian, Knott, & Magiati, 2012). Adolescents with ASD may have difficulty expressing anxiety verbally
and, therefore, may express it through overt behaviors (e.g., aggressive behavior,
meltdowns), sensory behaviors (e.g., chewing clothing, licking lips), or avoidance
(e.g., refusal to go on a trip). These episodes of anxiety may occur frequently and
be difficult to soothe (Auger, 2013; Ozsivadjian, Knott, & Magiati, 2012).
During adolescence, teens with ASD may continue to experience difficulties
building relationships with peers and interacting socially. These difficulties may
include the subtleties of communication, such as not understanding tone of voice;
facial expressions and body language; or figurative language, humor, and sarcasm
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(NIMH, 2016a. According to Demurie, De Corel, and Roeyers (2011), when compared
to teens without ASD, those with ASD tend to have less ability to experience feelings
of warmth, compassion, and concern for others and feel less personally distressed
in response to situations where others feel distressed. Adolescents with ASD report
fewer friendships and reciprocal relationships when compared to peers (RotheramFuller, Kasari, Chamberlain, & Locke, 2010; Rowley et al., 2012), face peer rejection
more often, and are overly represented as victims of bullying (Sreckovic et al., 2014).
As noted in the previous “Voices from the Field” sidebar, children with ASD may
talk at length about a favorite subject but do not give others a chance to respond or
even notice when others lack interest in the topic they are discussing. In adolescence,
when teens are struggling to fit in with peers, this tendency can lead to peer rejection,
avoidance, and bullying (Auger, 2013; Sreckovic et al., 2014). That said, ASD is not a
degenerative disorder, and many children and adolescents can learn to compensate
for ineffective social behaviors over time (Auger, 2011). Counselors can teach social
skills and teach clients with ASD to use social behavior logs to help them reflect on
social interactions that went well or those that didn’t. The counselor and client can
review the logs during counseling sessions and rehearse more socially appropriate
responses to use in the future. The vignette that follows highlights my (Tori’s) work
with Suzanna, a highly intelligent adolescent girl who was diagnosed with ASD.
Case Illustration: Suzanna
Suzanna, a 13-year-old girl with an IQ of 145, wore glasses and had braces. She
had a tendency to laugh at inappropriate times and to correct the teacher and
other children in a condescending way. In lieu of appropriate eye contact, she
would switch between staring at the person she was talking to, and then looking
away very quickly, which made for awkward and somewhat strange interactions.
She read 15 to 20 books a week and had an encyclopedic knowledge of insects
and reptiles that she liked to share with her classmates, regardless of their level
of interest. As you can imagine, the combination of these behaviors made life in
middle school difficult for Suzanna. She came to see me in the school counseling office and asked if I could help her make just one friend, which I agreed to
as long as she was open to examining her social behaviors and discarding those
behaviors that didn’t work well for her. Over the next few months, Suzanna and I
practiced eye contact using a small hand mirror. I also observed her in the classroom and made notes about behaviors that seemed off-putting to other kids. Together, we reviewed these notes, rehearsed more appropriate responses during
our weekly visits, and practiced reciprocal conversation. When she did this well,
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we celebrated with Skittles, and when it didn’t go so well, she had to identify what
didn’t work and make a new plan of action. After 2 months, Suzanna had made
progress in individual sessions, so I formed a group with other young teens who
also needed social skills support. In group, we practiced taking turns, looking
interested, making appropriate eye contact, and starting conversations. By the
end of the school year, Suzanna and one of the girls in the group had become
friends (mission accomplished!). Years later, I ran into Suzanna’s mother. She
shared that Suzanna was attending an Ivy League college and thanked me for
helping her daughter. She said that Suzanna credited me for this accomplishment.
These words of thanks were well worth my efforts!
Like Suzanna, many high-functioning children on the Autism spectrum have
special strengths and abilities. These abilities may include above-average intelligence,
the ability to easily learn and remember detailed information, strong auditory and
visual learning skills, and strong skills in a specific subject area (i.e., math, science,
music, or art) (NIH, 2016a).
Interventions for Children and Adolescents With ASD
The following interventions can be used to help children and adolescents with ASD.
We will explore several in the next section.
Structure and Routine
School-based mental health providers can provide tremendous emotional support to
children and adolescents with ASD by helping to ensure all stakeholders maintain
structure, routine, and consistency throughout the school day. Adults should provide
students with ASD advanced warning regarding normal transitions and any disruptions
to the school schedule, such as assemblies and fire drills (Auger, 2011). Accommodations
should be made for those who may be experiencing sensory overload because of these
events. For example, an assembly with loud music and a large video display may be
fun for neurotypical children but upsetting and anxiety provoking for children with
ASD. A bit of advanced planning, such as allowing them to go to the library rather than
attend the assembly, can help children and adolescents with ASD succeed at school.
Social Stories
Social stories can be used to support and potentially improve the social skills of
children and adolescents with ASD (Goodman-Scott & Carlisle, 2018; Hutchins,
2012; Kaffenberger & O’Rorke-Trigiani, 2013). This hands-on, visual approach can
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be used to address social, behavioral, and communication skills deficits associated
with the disorder. Social stories can also help to explain a social situation or concept
using simple language and a description of the point of view and feelings of others.
When creating a social story, the counselor and client can work together to write and
illustrate their story, and parents and teachers can be consulted regarding important
details (Goodman-Scott & Carlisle, 2018; Kaffenberger & O’Rorke-Trigiani, 2013).
Using social stories can help the child or adolescent understand what happened,
why it happened, and how to respond in a future social situation (Rhodes, 2014).
Community-based Programs
Intensive, community-based programs to address social skills, anxiety, and other
common concerns children and adolescents with ASD face have shown promise
in recent years (Webb, Miller, Pierce, Strawser, & Jones, 2004; Wood et al., 2009).
Webb and colleagues (2004) used the SCORE skills strategy intervention during a
10-week program targeting 10 high-functioning adolescents with ASD. The program concentrated on the development of social skills such as sharing ideas, giving compliments,
helping or encouraging others, and exercising self-control. Group instruction included
demonstrating and role playing these skills (Auger, 2013). The intervention program
resulted in improvement rates of 10% to 50% in all five skill areas, although parents did
not report significant improvement in the skill areas at home (Webb et al., 2004).
Wood and colleagues (2009) described a comprehensive community-based program to target anxiety symptoms in children with ASD. Treatment included 16 weekly
family sessions focused on working with the child and the parents, a peer support
system at school, mentoring, behavioral rehearsal at school and before play dates,
and a comprehensive behavior reinforcement system. Training was provided in areas
such as coping skills, parent education, personal hygiene, and odd behaviors that
could lead to peer rejection and ridicule (Auger, 2013). The program was successful
with 78.5% of children in the treatment group showing overall improvement and
more than half of the treatment group showing remission of all anxiety disorders
post-treatment and at 3-month follow-up (Wood et al., 2009). Counselors working
with young clients with ASD may consider creating a list of local community support
services and make it available to parents and guardians.
EMOTIONAL DISTURBANCE (ED)
Emotional disturbance is an umbrella term that covers a number of mental health
disorders that may manifest in children and adolescents (Center for Parent Information
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and Resources, 2017). IDEA (2004) defines the category of emotional disturbance (ED)
as a condition with specific characteristics over a long period of time that adversely
affects educational performance to include the following: (a) learning difficulties not
explained by other disabilities, (b) an inability to build and maintain relationships, (c)
inappropriate behavior, (d) pervasive mood of unhappiness, and (e) the tendency to
develop physical symptoms or fears associated with personal problems. Children and
adolescents with an emotional disturbance (ED) may be diagnosed with a specified
disorder such as anxiety, depression, bipolar, conduct, obsessive-compulsive, and/or psychotic. Behaviors related to ED often diminish the ability for these individuals to achieve
academic and social success (Center for Parent Information and Resources, 2017).
Impulsivity, acting-out behaviors, withdrawal, immaturity, and academic difficulties can
range from mild challenges when interacting with others to serious violations toward
self, others, animals, and property (Council for Exceptional Children, 2017). When
properly diagnosed, these children and adolescents can receive counseling services to
support their functioning to increase their personal and educational opportunities.
A brief overview of the most common emotional problems children and adolescents
experience follows. This information will help counseling practitioners to better
understand how these disorders impact children, adolescents, and their families.
Anxiety Disorders
While it is normal for children and adolescents to experience some occasional worry,
anxiety that is excessive, persistent, uncontrollable, and overwhelming and involves
irrational fears limiting daily activities may be indicative of an anxiety disorder (NIMH,
2016b). Anxiety disorders are very prevalent in young people and are characterized
by excessive worry that causes significant distress most days for at least six months.
Symptoms of restlessness, difficulty with concentration, irritability, and/or sleep disturbance that cannot be explained by other causes are also present (APA, 2013).
Anxiety disorders include several discrete disabilities that share core characteristics of excessive, irrational fear. Common anxiety disorders are generalized anxiety
(GAD), separation anxiety, obsessive-compulsive (OCD), panic, posttraumatic stress
(PTSD), social anxiety (also called social phobia), and specific phobias (Council for
Exceptional Children, 2017).
Clinical Depression
Sadness is a normal response to the challenges and disappointments children and
adolescents experience. However, when sadness is so severe that it interferes with
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daily functioning and the enjoyment of life, a diagnosis of clinical depression should
be considered. Children and teens who are experiencing clinical depression may
be irritable, sad or moody, have trouble sleeping or paying attention, experience
academic difficulty, withdraw from friends and activities, act out aggressively, lack
motivation or energy, and think of death or suicide (APA, 2013). A combination of
counseling, such as cognitive behavior therapy, and medication has been proven
to be effective in treating depression in children and adolescents. Exercising daily,
getting adequate sleep, and eating healthy foods may also help (NIMH, 2016c).
Bipolar Disorder
Bipolar disorder is a serious medical condition that causes intense mood swings from
manic episodes characterized by persistently elevated, energetic, or irritable mood
to depressive episodes that include intense sadness and hopelessness. Significant
changes in energy, activity, and behavior accompany these debilitating changes in
mood (Council for Exceptional Children, 2017). This cycle repeats over time with
periods of normal mood in between. Evidence-based research has shown that a
combination of medication, cognitive behavior therapy, and family therapy are
recommended to treat this disorder (NIMH, 2016b).
Interventions for Anxiety and Depression
There are numerous interventions that can be used to treat children who are diagnosed with clinical depression or an anxiety disorder. We will explore counseling,
stress management, and creative approaches in the next section.
Counseling
Rational-emotive and cognitive behavior therapy can be an effective treatment
for both depression and anxiety (Vernon, in press). Clients are taught to examine
their thoughts to change their feelings and behaviors. For example, children and
adolescents often overgeneralize and assume the worst-case scenario, so helping
them realistically examine the possibility of something bad happening versus the
probability of it happening can significantly reduce anxiety. Small group counseling can also be beneficial because clients can gain support from the leader and
group members and recognize they are not alone in their experience (NIMH,
2016b, 2016c).
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Stress Management
Meditation, mindfulness, and yoga can be helpful to clients with depression and
anxiety by teaching them to clear their mind of troubling thoughts, center themselves
in the present moment, and relax. Physical exercise can also be useful (Cook-Cottone,
2017). Another effective technique is to use breathing exercises. Breathing slowly
can reduce anxiety because it helps to slow the heart rate and naturally calms the
body systems involved in fight/flight/freeze response (Boyes, 2016).
Creative Approaches
Bibliotherapy, journaling, and keeping a thought diary are helpful with young clients who are struggling with depression and anxiety. For example, Vernon (2002)
presented the story of “Anxious Albert,” a little boy who worried about everything.
Albert’s story can be read to anxious children and used as a way to introduce coping
skills. Counselors can also encourage their clients to use a thought diary to keep
track of situations, what they tell themselves about those situations, and how worried or upset they become as a result (Markway, 2014). Thought diaries can help
clients gain awareness of and perspective on their thoughts, which is the first step
in changing them. Vernon (2002) suggests inviting clients to take the lyrics from
sad songs they typically listen to when depressed and “take a sad song and make it
better” by rewriting more uplifting words (p. 135).
Oppositional Defiant Disorder (ODD)
Children and adolescents diagnosed with ODD display a pattern of angry/irritable
moods, argumentative/defiant behaviors, and vindictiveness. These clients present
as angry, easily annoyed, noncompliant, and spiteful (APA, 2013). They fail to take
responsibility for their actions and often blame others for their problems. Parent-child
interaction therapy (PCIT) (Eyberg, 2008) is a popular evidence-based treatment for
ODD. Parents are coached by a therapist to increase positive interactions with the
child and to set consistent consequences for undesirable behavior. Children learn
to increase compliance, control behavior, and enjoy better relationship with their
parents and caregivers (Child Mind Institute, 2018).
Conduct Disorder (CD)
Children and adolescents diagnosed with conduct disorder (CD) have difficulty
following rules and typically exhibit an array of problematic behaviors that are not
socially acceptable, including aggression toward people or animals, destruction
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of property, deceitfulness and/or theft, and truancy or other serious rule violations (APA, 2013). Conduct disorder in children and adolescents often results in
the development of an antisocial personality disorder in adults. Early diagnosis
and treatment improves the long-term outlook for children and adolescents with
CD (Child Mind Institute, 2018). Parent education, family therapy, training in
problem-solving skills, and community-based family services may be helpful for
children and adolescents diagnosed with CD, as well as for their families (Council
for Exceptional Children, 2017).
Interventions for Young Clients With ODD and CD
There are many interventions that can be used with children and adolescents with
ODD and CD to help them cope with their disorders and increase academic success.
Interventions should focus on three main concepts: (a) understanding the disruptive
behavior, (b) identifying interventions that can reduce the disruptive behavior, and
(c) establishing a connected relationship with the child (Auger, 201).
Understand the Disruptive Behavior
Adults working with children and adolescents with conduct disorders and oppositional defiant disorders should try to understand what is causing or supporting
it: the triggers. Behavioral triggers can come in many forms; some are simple and
physiological (e.g., hunger, inadequate sleep) and some are emotional (e.g., conflict
with an adult or peer, feeling left out by other children). Whenever possible, adults
should attempt to minimize triggers to problem behaviors by intervening when
children are engaging in problematic behavior, structuring activities, and rewarding
positive behaviors (Auger, 2011).
Find Interventions That Work to Reduce the Disruptive Behavior
A simple strategy that can minimize behavioral triggers is giving students choices
rather than issuing directives. For example, instead of saying, “Do your homework”
a parent might say, “Would you like to start with math or English today?” Giving
choices (within limits) is a way to help them be accountable for their actions (e.g.,
“If you choose to complete your homework, you can play video games”). Giving
choices can help prevent power struggles (Glenn & Nelsen, 2000).
In schools, children with behavioral disorders often receive in-class or out-of-class
time-out as a disciplinary consequence. However, students miss instruction while in
time-out and, because they are often sent to time-out when they are angry or upset,
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they may resist the time-out and disrupt the class (Wright, 2013). Active-response
beads-timeout (ARB-TO) (Grskovic et al., 2004) is an easy-to-use intervention to
replace in-class time-out. Essentially, the teacher creates a set of beads and trains
all students in the class to use the beads as a way to relax when they are upset. The
teacher directs the disruptive student to get the beads, praises the student for doing
this, and says to the student ,“Put your head on the desk and use the beads to count
to 10 while taking deep, relaxing breaths.” The ARB–TO promotes the use of calmdown strategies, can enhance self-management skills, and minimizes exclusion from
class time (Grskovic et al., 2004).
Teaching anger management strategies can be very useful, and, once learned, they
can be applied to any situation that upsets the child or adolescent. Creative techniques are the most effective. One strategy that I (Tori) use frequently is a prop—a
plastic Coke bottle (Jacobs & Schimmel, 2013). I shake the bottle to demonstrate the
negative, sometimes untrue things that the child is telling him- herself that leads to
anger. I ask the child to touch the bottle so that he or she can feel how the pressure
in the bottle has caused it to become firm. We talk about the fact that the bottle
would explode if I opened it, just like some kids do when they are angry. We then
discuss using self-talk, rational coping statements, and deep breathing to reduce the
anger. I encourage the client to pay attention to physical sensations, which can serve
as a trigger to prevent the anger “explosion.” This combination of REBT (Vernon,
in press) and creative techniques is a quick, effective way to teach children and
adolescents about their anger.
Other effective strategies to reduce disruptive behaviors include the use of positive behavioral interventions and supports (PBIS), such as a token economy (small
rewards for good behavior that can lead to larger incentives), behavior contracts,
and relaxation skills (Council for Children with Behavioral Disorders, 2017). Mindfulness, meditation, and yoga also can be used to help students with ED to build
self-awareness, control impulses and increase attention, and develop empathy and
compassion for others (Cook-Cottone, 2017).
Establish a Connection With the Child
While it may be more difficult to establish a relationship with children or adolescents
with ODD or CD, it is possible. In fact, although all children and adolescents benefit
from connected relationships with adults, they are critical for children with low
levels of social support (Leibert, Smith, & Agaskar, 2011). The behaviors, thoughts,
and feelings of young clients with disruptive behaviors can contribute to negative
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interactions with peers and adults that may result in social failures and ineffective
relationships. Although they may want to connect positively with peers and adults,
they are more likely to attribute negative or aggressive meaning to others’ behavior
and/or feel they are being treated unfairly. This may lead to aggressive or irritating
behaviors that can further alienate peers and adults (Grothaus, 2018).
There are several ways that school and mental health practitioners can build a
connected, trusting relationship with a child or adolescent with ED. Active listening,
identifying the feelings behind the behaviors, and focusing on the choices available
can help them feel heard and empowered (Christiansen & Duncan, 2014). Interpersonal skills such as being authentic, using humor, and demonstrating respect to
the young client, regardless of his or her behavior, can also establish a foundation
of trust and mutual respect (Runyan & Grothaus, 2014).
GIFTEDNESS
Giftedness refers to individuals who demonstrate outstanding levels of ability or
achievement in one or more areas, which includes a symbol system, such as mathematics or language, and/or a set of sensorimotor skills, such as painting, dance,
or sports. Approximately 3.2 million public school students participated in gifted
and talented programs during the 2011–2012 school year (NCES, 2017). These students were evenly split by gender, over-represented by Asian students (13%), and
under-represented by Hispanic (4.6%) and Black (3.6%) students (NCES, 2017). Individual states determine regulations related to gifted and talented students, which may
fall within the code for special education. Since these students progress in learning
at a noticeably faster pace from their peers, they may experience barriers to their
attainment due to environmental, educational, and emotional factors. Counseling
can provide additional support for gifted students to realize their potential in their
area of giftedness as well as academic, social-emotional, and career development.
A complicating factor in identifying students who are gifted is that each state sets
the standard for the qualification of gifted. However, in reauthorizing the Elementary
and Secondary Education Act (ESEA) of 1965 through the Every Student Succeeds
Act (ESSA, 2015), a definition of gifted and talented students is provided (Title VIII,
Part A, Definition 27, p. 393): students, children, or youth who give evidence of high
achievement capability in areas such as intellectual, creative, artistic, or leadership
capacity, or in specific academic fields, and who need services and activities not
ordinarily provided by the school to fully develop those capabilities.
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The National Association for Gifted Children (NAGC) is an excellent source for
information about giftedness. According to NAGC, “[G]iftedness may manifest in
one or more domains such as intellectual, creative, artistic, leadership, or in a specific
academic field such as language arts, mathematics, or science” (NAGC, n.d.a). A
good rule of thumb is that individuals who are in the top 10% in relation to national
and/or local norms in expected performance are considered gifted (NAGC, n.d.a).
Prominent theoretical frameworks for giftedness include Robert Sternberg’s theory of
successful intelligence, Howard Gardner’s theory of multiple intelligences, Francoys
Gagné’s differentiated model of giftedness and talent, and Joseph Renzulli’s gifted
behavior (NAGC, n.d.b).
NAGC’s (2009) position statement specifically points out the need to attend to the
well-being and universal and unique developmental experiences, and to “intentionally, purposefully, and proactively nurture socio-emotional development in these
students” (para. 2). The American School Counselor Association’s (ASCA) position
statement on students who are gifted and talented identifies personality characteristics such as perfectionism, sensitivity, and idealism that can lead to detachment,
isolation, and problems with self-regulation (ASCA, 2013, p. 28).
Giftedness can be both an asset and a challenge to the individual because while he
or she may have remarkable ability in one or more domains, he or she also may be
at risk for poor personal and educational outcomes (Wood & Peterson, 2018). Being
gifted does not preclude a child or adolescent from dealing with life’s stressors and
from being no more nor less likely than their same-age peers to deal with mental
health issues and disorders, according to Wood and Peterson. What is true is that
students who are gifted are different from their peers and experience asynchronous
development (Silverman, 2012). This uneven development is seen when the child’s
giftedness is far ahead of same-age peers, and the gifted student feels out of sync.
Asynchronous development also results in significant differences between one’s
giftedness and level of social and emotional development. Although they may be
gifted, they may also be immature. In school, they may be bullied, ostracized, or
made fun of by their peers who feel inferior. Loneliness is a significant predictor of
psychological symptoms, which include depression and anxiety (Wood & Peterson,
2018). Parents should be aware of disordered eating, self-injury, relational conflicts,
and social withdrawal that may indicate the onset of mental health concerns.
Gifted racial/ethnic minority students experience double-tier difficulties: challenges as a minority and dealing with psychosocial problems as a gifted student
(Woo, Bang, Cauley, & Choi, 2017). Negative racial stereotypes and racial/ethnic
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prejudices may result in students experiencing discriminatory stress in educational
contexts, such as being discouraged to enroll in advanced-level classes, being wrongly
disciplined, and experiencing negative peer pressure stemming from “acting white”
(Woo et al., 2017, p. 201).
Children and adolescents who are gifted and also have a learning disability (G/LD),
generally referred to as twice exceptional, present unique challenges. These individuals
are significantly under identified, underserved, and many times overlooked when
being assessed for either giftedness or learning disabilities (Beckmann & Minnaert,
2018). Consequently, they may not receive the necessary support in their unique
social-emotional development, which may result in acting out or odd behaviors, poor
self-concept, and isolation from their peers (Beckmann & Minnaert). It is important
to approach assessment holistically and considering non-cognitive characteristics such
as frustration, which, in particular, is strongly recommended. Recognizing the G/LD
individual’s strengths and weaknesses will provide more “fine-grained insights into
their sometimes conflicting needs” (Beckmann & Minnaert, 2018, p. 18).
Interventions for Children and Adolescents Who Are Gifted
Counseling should be provided to help children and adolescents who are gifted to deal
with anxiety, depression, perfectionism, fear of failure, excessively high expectations
of self and/or by others, social skills, and managing emotions. Strength-based, reframing, and emotive approaches, as well as rational-emotive and cognitive-behavior
therapies, can help gifted individuals embrace their uniqueness while attending
to asynchronous development in other areas of their lives. School counselors can
accommodate the needs of gifted students through classroom lessons (RTI tier 1),
small group counseling (RTI tier 2), and individual counseling (RTI tier 3). At the
same time, they may need services in mental health settings if more severe psychological problems develop and more intense treatment is warranted. Counseling
professionals need to collaborate and consult with teachers and parents to provide
information and strategies so that children and adolescents who are gifted can make
the most of both their exceptionality and developmental milestones.
Case Illustration: Velma
Velma, a 12-year-old, was promoted from seventh to ninth grade due to her exceptional math ability. Within the first four weeks of the fall semester, all her teachers except for her math instructor had spoken to me (Pam) about Velma’s imma-
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turity and underachievement. “If she is so smart, then I expect her to be at least
as good as most of the students I am teaching” was the typical comment. When
pressed for examples of their observations, they said that she was childish and
didn’t participate in class discussions.
Velma seemed pleased when I asked to meet with her in my office during lunch,
and I was eager to learn how her ninth-grade experiences had been thus far. She
quickly told me how excited she was about her math class but was less forthcoming about her other classes. When I asked her give me the top three classes she
liked other than math, she sat quietly and stared at her sandwich. I tried another
approach by asking, “What do you miss most about seventh grade?” She teared
up and talked about her best friend, Kate.
This opened my eyes to the loneliness that Velma was experiencing. Although
our high school could provide the intellectual challenge in math, we had not met
this 12-year-old’s basic need of belonging. I reached out to her teachers and found
two who wanted to help create a supportive environment. The English teacher revised the essay topics in his composition class so that everyone would engage in
self-reflection. The freshmen math teacher put together a team of star students
who would get together to create online math tutorials to help students review
topics outside of class. These collaborative approaches provided opportunities
for Velma to reflect on her developing identity as a unique individual, increase
her sense of belonging with same-age peers, and tap into her giftedness in math.
Reflect on various aspects of giftedness by referring to the “Now Try This!” sidebar.
NOW TRY THIS!
When working with kids who have difficulty with emotion regulation, you
need to do everything possible to control the environment to make it more
tolerable for them. Some examples are turning down the lights, moving the
child away from a noise or sensation that is overly stimulating, or presenting
him or her with items that can help him or her to self-sooth (e.g., sand, putty,
sensory toys, etc.). For children with autism, there are a variety of products,
such as body socks, sensory pods, and noise canceling headphones that
can be invaluable during emotional tsunamis. The trick is to figure out what
works for the individual child, not take a one-size-fits-all approach. Take a
look around your office; what can you do to control the environment in your
office to be more therapeutically helpful?
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COUNSELING CHILDREN AND ADOLESCENTS
WITH EXCEPTIONALITIES
Most children and adolescents with exceptionalities experience developmental
challenges. The dissonance between their chronological age and social-emotional
development can be frustrating and may result in behaviors that can impede positive experiences in the home and school environment. Oftentimes, adults are more
aware of the exceptionality and overlook other developmental aspects, which may
cloud a more textured understanding of the exceptional student. These children
can be extremely idiosyncratic and may exhibit heightened sensitivity, intensity,
over-excitability, asynchronous development, and mental health issues that include
anxiety, depression, and other emotional difficulties.
Children and adolescents with ADHD, autism, and ED all share a difficulty with
executive functions—most notably, inhibiting impulsivity and regulating emotion.
Counseling young clients with these difficulties requires patience and skill on the
part of the practitioner, as well as a few tricks of the trade that can help to de-escalate
children struggling with emotion regulation. Children displaying giftedness need
assistance in learning how to interpret their environment, and counselors are in
a position to provide the information and sensitivity to help them. The following
sections provide an overview on medication, attention to environment, and selected
techniques to use when counseling children and adolescents with exceptionalities.
MEDICATION
Using medication to modify children’s behavior has proven effective with quick
response rates (Ryan, Katsiyannis, & Ellis, 2015). Medication-based interventions
target endogenous variables that influence behavior or interact with exogenous
variables to regulate behavior (Lloyd, Torelli, & Symons, 2016). Many children with
emotional and behavioral disorders (E/BD) are prescribed psychotropic medication to regulate neuronal activity, which results in temporary changes with mood,
perception, consciousness, or behavior (Lloyd et al.,). Early findings suggest that a
combination of medication and therapy produce the best results (Ryan, et al.). The
most commonly prescribed classes of psychotropic medications for children and
adolescents include antidepressants, adrenergic agonists, new and atypical antipsychotics, anxiolytics, beta-blockers, mood stabilizers, selective norepinephrine
reuptake inhibitors (SNRIs), antiepileptics, and stimulants (Ryan, Katsiyannis,
& Ellis, 2015). The National Institute of Mental Health provides information on
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medications (NIMH, n.d.). Table 8.1 is a helpful resource on psychotropic medications for counseling professionals (NIMH, 2016d).
TABLE 8.1. Psychotropic medications: Classes of psychotropic medications for
children and adolescents
Class of psychotropic
medication
Example
medications
Therapeutic effect
Possible side effects
Antidepressants
Paxil
Prozac
Zoloft
Improve mood, cognitive and psychomotor functioning,
and concentration
Fatigue, drowsiness,
sleep disturbance, agitation, suicidal ideation
Adrenergic agonists
(antihypertensives)
Catapres
Kapvay
Tenex
Treat tics, Tourette
syndrome, behavior
disorders, self-injury,
aggression
Sleepiness or sedation,
irritability, confusion
New and atypical
antipsychotics
Clozaril
Risperdol
Reduce psychotic
symptoms; improve
mood; reduce irritability
Nervousness, restlessness or inability to sit
still; sadness, sleepiness, or sedation; disrupted sleep; suicidal
ideation
Anxiolytics
Valium
Xanax
Benadryl
Tranquilizing effect
on central nervous
system, seizure
control, severe
agitation, Tourette
syndrome
Decreased cognitive
performance, behavior
disinhibition, irritability,
sleepiness
Anxiety, explosive
and violent behavior, self-injury,
aggression
Fatigue, insomnia, mild
symptoms of depression
Beta-blockers
Mood stabilizers
Lithium
Decrease intensity
of manic behavior;
decrease aggression
Confusion, sleepiness,
or sedation
Selective norepinephrine reuptake
inhibitors (SNRIs)
Strattera
ADHD
Anxiety, agitation, apathy, suicidal ideation
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Antiepileptics,
anti-convulsants
Depakote
Klonopin
Lamictal
Reduce seizure
activity; reduce aggressive behavior
Sedation, fatigue, irritability, behavior disinhibition, overexcitement,
memory loss, difficulty
concentrating
Stimulants
Adderall
Ritalin
Dexedrine
Improve concentration, motor activity, goal-directed
behavior; decrease
disruptiveness and
distractibility
Irritability, confusion,
withdrawal exacerbation of motor/vocal
tics, anxiety, sadness,
increased nervous
habits
Source: NIMH (2016d); Ryan, Katsiyannis, & Ellis (2015)
There is a paucity of statistical evidence related to therapy and medication, also
referred to as pharmacotherapy, among students with disabilities (Sullivan & Sadeh,
2015). However, in one recent nationally representative study of adolescents with
disabilities, Sullivan and Sadeh (2015) found that 18.4% used at least one psychotropic
medication. Pharmacotherapy was most prevalent among adolescents with other
health impairments that include attention deficit hyperactivity and epilepsy (44.64%),
autism (42.46%), and emotional disturbance (40.62%). Significant socio-demographic
differences in treatment were reported by race/ethnicity and insurance status with
racial minorities, and students without insurance were significantly less likely to
receive pharmacotherapy (Sullivan & Sadeh, 2015).
School and mental health counselors are not likely to be distributing medication
per se, but, as part of a collaborative team approach, it is important to monitor and
communicate the child’s progress and possible side effects related to prescription
medications. Data collection based on observations and outcome measures will help
to track progress and medication effects.
ATTENTION TO ENVIRONMENT
Children with developmental disabilities, such as autism and ED, may be more
sensitive to environmental stimuli than their neuro-typical peers. They also may
lack the self-regulatory and language skills to communicate their needs calmly
in times of distress. Therefore, the counselor must sometimes intuit the source of
distress from the child’s behavior. For example, children with Sensory Processing
Disorder (SPD), a common part of the autism profile, which can include sensitivity to light, sound, certain fabrics, and food textures, may pull at their clothing or
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scratch at their skin in times of distress. This may be a sign that a shirt that was
tolerable during emotional calm has now become intolerable and uncomfortable.
Difficulties caused by SPD can lead to anxiety, challenging behavior, poor academic
performance, and isolation from peers (Autism Awareness Centre, 2010). Modifications to environmental stimuli, such as dimming the lights, using a noise machine,
and having a variety of sensory items on hand (Kinetic Sand, Thinking Putty, clay,
Playdough, fidgets), can help children calm down and begin to regulate their emotions. Flexible seating options (beanbags, yoga balls, pillow piles on the floor) can
make them more physically comfortable and help them exert some control over
their circumstances, which can be empowering and useful. The case illustration of
Tim at the beginning of the chapter describes my (Tori’s) work using environmental
modifications to curtail behavioral outbursts caused by poor emotion regulation in
a child with autism. Read one counselor’s ideas on creating a calm environment in
the “Personal Reflection” sidebar.
PERSONAL REFLECTION
Now that you have read about giftedness as an exceptionality, reflect on
each of the following questions: (a) How can you increase your awareness
of and strategies to support the socio-emotional development of gifted
individuals, particularly those who are twice exceptional? (b) Are you knowledgeable about how your state and school district identify giftedness? (c)
Do you have a negative stereotype embedded in your view about gifted
racial/ethnic minority children and adolescents? (d) What are strategies that
you can use in counseling exceptional children and adolescents?
THEORY-BASED INTERVENTIONS
There are a number of effective therapeutic interventions that have been used successfully when working with exceptional children and adolescents with giftedness
and developmental disabilities, such as ADHD, autism, and emotional disabilities. Learning approaches to counseling that are developmentally appropriate and
evidence-based should link thinking, feeling, and behaving. Individual and group
counseling that focus on relationships, personal concerns, and developmental tasks
can help these children and adolescents benefit from their life experiences. Individual student planning covers a range of services that includes setting personal
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goals; assessing strengths, interests, skills, and abilities; monitoring strengths and
challenges; and planning for post-secondary pursuits. Several theory-based techniques follow:
APPLIED BEHAVIOR ANALYSIS (ABA)
Applied behavior analysis (Baer, Wolf, & Risley, 1968) focuses on changing children’s
behavior through positive reinforcement and rewarding desired behavior, redirection,
and replacement of undesired behaviors. Ongoing evaluation is an important part of
the ABA process to determine if the interventions are working, and modifications
are made as needed to ensure consistent and ongoing progress. Over many decades
of research, behavior analysts have developed a number of techniques to increase
useful behaviors and reduce those that may cause harm or interfere with learning.
ABA must be delivered by a trained analyst who works with clients in their home
or at an agency as a part of an early intervention or comprehensive support plan to
help develop goals and treatment plans to improve behavior and learning in children with ASD (Autism Speaks, 2018). ABA therapy has been proven effective with
autism spectrum disorders, intellectual and developmental disabilities, attention
deficit disorder, behavior disorders, and many other common medical and mental
health concerns affecting children and adolescents (Association of Applied Behavior
Analysts, n.d.; Autism Speaks, 2018).
SOLUTION-FOCUSED TECHNIQUES
As you read in chapter 5, solution-focused brief counseling (SFBC) provides a practical
focus on solutions with clearly defined goals and methods to evaluate progress (Sharf,
2012). Techniques such as scaling, exceptions and reframes, the miracle question,
and goal setting all help clients solve their problems. For example, a counselor can
ask a child dealing with anxiety to give a rating for the day: “Give me a thumbs up
if today was a good day or a thumbs down if today was not a good day. Tell me what
happened today that is a thumbs [up/down].” Reframes are also helpful so that young
clients with exceptionalities do not “become” their diagnosis. For example, instead
of being ADHD, the reframe could be that the child simply has a lot of energy that
needs to get channeled in new ways. Also, the miracle question can be helpful for
a gifted child who seems to have no friends and is introduced by saying, “Suppose
a miracle happened while you were sleeping and when you woke up you had a best
friend. Describe what you and your best friend would do.”
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As you read in chapter 5, goals need to be concrete, doable, and have buy-in from
the client. Goals can be monitored with scaling to measure progress. For example, in
the vignette with Tim at the beginning of the chapter, the feelings thermometer was
used by the counselor to help Tim set a goal. “You really like the feelings thermometer. Would you be willing to set a goal of having more “cool” moments rather than
“hot” moments each day? Good. Let’s work on a way you can record the number of
cool, warm, and hot moments each day so you can check in with your mom or dad
when you get home from school.”
REALITY THERAPY TECHNIQUES
As described in chapter 6, reality therapy helps counselors and clients focus on
meeting basic needs, making choices, and taking responsibility (Sharf, 2012). Techniques that can be helpful to youth with exceptionalities include basic needs, quality
world, SMART goals, and WDEP. Counselors can help young clients choose more
productive ways to meet their needs when they understand the clients’ perspective
regarding how the total behavior is meeting which need (or needs). For example, an
adolescent with a conduct disorder who has been court-referred may be resistant to
engage in the counseling process. Her counselor, who noticed the black nail polish
the client was wearing, said, “I am impressed with your attention to wearing nail
polish. What makes you want to take the time to put it on?”
Read about a technique that can be helpful to use with adolescents diagnosed with
conduct disorder in the “Add This to Your Toolbox” sidebar.
ADD THIS TO YOUR TOOLBOX
Building a working alliance with adolescents diagnosed with conduct disorder can be challenging. One of my (Pam’s) techniques that seemed to take
court-ordered clients off-guard was to find something they were doing that
could be highlighted as a positive and engage them in a way to do more
of that behavior. For example, an adolescent male used the WDEP from
reality therapy to increase his knowledge about professional basketball by
watching games, keeping track of his favorite players’ statistics, and improving his own jump shot. When we can engage clients with what they are
interested in, we can enhance the working alliance, which can pave the way
to work on court-ordered goals.
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Counselors can also help young clients identify their quality world. For example,
a child with a specific learning disability who is struggling with her social skills
may need help identifying who is in her quality world. The counselor can provide
an extra-large picture of a blank cell phone and say, “Let’s add names of who you
want as your ‘contacts’ and draw a picture on the cell phone for each ‘contact.’ Then,
we can organize your ‘contacts’ as study-buddies, playmates, and lunch bunch.”
Reality therapy also teaches clients a SMART (specific, measurable, attainable, relevant, and time-bound) goal sentence structure. For example, an adolescent who has
been diagnosed with clinical depression may find a SMART goal helpful in identifying
and measuring positive progress: “By the end of this month, I will increase my daily
walking from 0 to 30 minutes.” Another helpful reality therapy concept is the WDEP
system to evaluate progress toward identified goals. For example, a child who is experiencing mood swings outside of what is expected is introduced to Eeyore “when he or
she is feeling really sad” and Tigger “when he or she is feeling really bouncy.” WDEP
can help the child choose to be Christopher Robin; identify what he or she is doing
when he or she is Eeyore, Tigger, and Christopher Robin; evaluate frequency for each;
and plan how to be Christopher Robin when Eeyore or Tigger shows up.
RATIONAL-EMOTIVE BEHAVIOR THERAPY TECHNIQUES
As you read in chapter 7, self-acceptance is a core REBT concept, and young clients
with exceptionalities struggle with accepting themselves. For example, many gifted
children and adolescents equate their self-worth with their performance, which results
in anxiety and a quest for perfectionism. A good concrete technique is to have the
adolescent client blow up a balloon, which represents his or her self-worth. Then, ask
him or her to poke a pin into the balloon and describe what happens—it deflates/it is
worth nothing. Use this strategy to engage the client in a discussion about the fact that
he or she is not like a balloon—if he or she makes a mistake, that’s all it is. It does not
take away from his or her worth as an individual (adapted from Vernon, 2002, p. 73).
An equally important REBT concept is that that everyone has strengths as well as
weaknesses (Vernon, in press). This is very applicable to young clients with learning
disabilities. Because they tend to define themselves as their disability, they need
to understand that everyone has strengths and weaknesses, and even though they
may have difficulty learning, they have other strengths. An easy way to convey this
concept is to draw a circle and fill it with + and – signs (see Figure 8.1). Counselors
can help the client identify strengths as well as weaknesses and emphasize that he
or she is “not” just the disability.
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FIGURE 8.1 Strengths and weaknesses.
TAKE-AWAYS FROM CHAPTER 8
As we conclude this chapter, we refer to the vignette at the beginning of the chapter
and discuss what I (Tori) learned about working with a child with an exceptionality
such as Tim’s. What was reinforced for me was the importance of paying attention
to the environment. For example, although taking off his shirt in an agitated state
might seem like extreme behavior, I did not overreact to this, and instead turned on
the fan. This low-reactivity stance is important in working with children such as Tim.
I also put Tim in charge of when he was ready to talk rather than when I decided
he should talk because I have learned from experience that this empowerment is
important for children with exceptionalities such as Tim’s. The technique I thought
was effective was helping Tim create a new plan by using the feelings thermometer.
He had ownership in the new plan that provided physical structure and emotional
support when he became frustrated.
After reading this chapter, you should now have more knowledge about the following key points for counseling children and adolescents with exceptionalities:
•
Being flexible; these children need patient, loving support from the adults in
their lives
•
Letting them play! Children who have difficulty with executive functioning
and emotion regulation need to be given the opportunity to move, touch, and
explore their environment
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•
Educating stakeholders about how to work effectively with children with
exceptionalities
•
Providing support for parents and teachers. Working with exceptional children provides both tremendous challenge and rewards, so assistance and
collaboration are necessary
•
Continuously learning; ongoing professional development is essential to staying current
•
Finding a network of supportive professionals for new ideas, consultation,
and supervision
HELPFUL WEBSITES
Autism
www.autismspeaks.org
Child Mind Institute
https://childmind.org
National Association for Gifted Children (NAGC)
https://www.nagc.org
The IRIS Center
https://iris.peabody.vanderbilt.edu
PRACTICAL RESOURCES
Baditoi, B. E., & Brott, P. E. (2015). What school counselors need to know
about special education and students with disabilities (rev.). Arlington, VA:
Council for Exceptional Children.
Cummings, R. (2016). The survival guide for kids with learning differences.
Minneapolis, MN: Free Spirit.
Senn, D., & McElvenny, K. (2014). Next steps to social success. Chapin, SC:
Youthlight.
Wood, S. M., & Peterson, J. S. (2018). Counseling gifted students: A guide
for school counselors. New York, NY: Springer.
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CHAPTER 9
Counseling Children and Adolescents
From Diverse Backgrounds
Darcie Davis-Gage
LEARNING OBJECTIVES
1.
To develop cultural awareness and identify culturally appropriate strategies
when working with young clients from diverse backgrounds
2.
To describe values associated with various ethnicities and religions
3.
To learn about gender identities and application of gender-sensitive counseling
interventions
A
yala is a 16-year-old 10th grader in a prominently Caucasian, Christian,
middle-class, public school. Ayala’s parents were referred to me by their
family doctor who attends their synagogue. Although the parents were very
reluctant to go outside of the Jewish community to discuss problems they were having
with their daughter, they were encouraged by their doctor who thought counseling
might be beneficial. Because they trusted his judgment, they contacted me to discuss
problems they were having with their daughter. Ayala, who had always been well
behaved and had not questioned the family’s traditional Jewish beliefs, was refusing
to attend services, was not following the dietary restrictions, and would not observe
the Jewish holidays. Her usually high grades had begun to decline and she was
becoming more defiant. When the family had discussed these concerns with leaders
at the synagogue, they found that there were other families who were dealing with
the same types of issues with their teenagers. Ayala’s parents were hoping she would
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agree to counseling but were also interested in my professional recommendations
because they did not want the problems to intensify.
In this particular case, I first familiarized myself with some Jewish practices by
reading literature, consulting with a colleague who often worked with clients from
a variety of faith backgrounds, and conversing with a local Jewish leader. When
Ayala and her parents attended the first session, I explained that the purpose of this
initial visit was to learn as much as I could about the problems so that I could make
recommendations about how to proceed. During this session, the parents described
what they had noticed. Ayala was somewhat reluctant to share her feelings, but she
did express that she wanted to “fit in” with her peers. She also said that she was
upset with her parents because she wanted to try out for football cheerleading but
her parents refused to allow this because the games were on Friday nights and she
was not allowed to miss services. She also said that she did not like eating at school
because her dietary restrictions made her feel different from her classmates.
After listening to more of Ayala’s concerns and talking again with her parents, it
seemed to me that Ayala would benefit from joining a counseling group of female
peers from a variety of faith backgrounds. I explained to the parents that because
“fitting in” is so important at this age that Ayala could find support in this group and
work through her feelings about being “different” and feeling alienated. I told them
that in the group, Ayala and her peers would have an opportunity to discuss healthy
identity development, gender roles, how to balance traditional beliefs while living in
the Western culture, and effective ways to communicate with parents. Since they were
somewhat reluctant to allow Ayala to participate in a group of this nature, I suggested
that they consult with leaders at the synagogue, as well as their family doctor. I also
assured the parents that I would increase my knowledge of various religious traditions
and worldviews to improve my competency as the group leader. After this consultation, the parents contacted me and said that their daughter could attend the group.
This proved to be a positive experience for Ayala, and in a follow-up session with the
family, the parents reported that Ayala was less defiant and things were much better.
As this vignette illustrates, counselors need to be prepared to work with young
clients from a culturally competent perspective. By understanding how Ayala incorporated gender, ethnicity, and religious practice into her identity, I was able to provide
relevant and effective counseling. I also felt that it was important to inform school
counselors, teachers, and administrators about how to create culturally inclusive
learning environments, so I offered a free in-service program at the high school
Ayala and the other group members attended.
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The purpose of this chapter is to identify strategies for developing cultural awareness when counseling children and adolescents from diverse backgrounds, genders,
and religious and spiritual practices. An additional focus will be on challenges
immigrant youth face, as well as numerous culturally sensitive interventions
A DIVERSE NATION
The population of the United States continues to become more diverse. When the 2020
Census is conducted, it is predicted that more than half of the nation’s children are
expected to be part of a minority race or ethnic group. By 2060, projections estimate
that just 36% of all children will be single-race non-Hispanic White, compared with
52% today. (United States Census Bureau, 2016). Religious and spiritual practices
are also changing due to the effects of education, the media, world consciousness,
and immigration. In the United States, the number of Christians is declining, while
the number of adults who do not identify with any organized religion is growing.
While the drop in Christian affiliation is particularly pronounced among young
adults, it is occurring among Americans of all ages. The same trends are seen among
all groups regardless of gender, ethnicity, or education level (Cooperman, Smith,
& Ritchey, 2015). In contrast, the gender demographics stay fairly consistent, but
the gender expectations and socialization of young people continue to evolve and
change (Sax, 2017). In the United States, about 150,000 youth between the ages of
13 and 17 identify as transgender, with the largest populations of these youth found
in California, Texas, New York, and Florida. The smallest populations are found
in North Dakota, Vermont, and Wyoming (Herman, Flores, Brown, Wilson, &
Conron, 2017). Counselors working with youth will find these changes reflected
in their caseloads and therefore must know how to acknowledge these differences
and incorporate culturally appropriate interventions into their counseling practice.
It is inevitable that professional counselors in educational and clinical settings
will work with young clients from diverse backgrounds. The American Counseling
Association (ACA) (2014) charges counselors with becoming culturally competent.
The preamble to the ACA Code of Ethics identifies “honoring diversity and embracing
a multicultural approach in support of the worth, dignity, potential, and uniqueness
of people within their social and cultural contexts” as one of the core professional
values (p. 3). The Multicultural and Social Justice Counseling Competencies provide
a conceptual framework for counselors working within this culturally diverse context (Ratts, Singh, Nassar-McMillan, Butler, & McCullough, 2015). This framework
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includes the developmental domains of counselor self-awareness, client worldviews,
the counseling relationship, and counseling and advocacy interventions. The American School Counseling Association (2015) adopted a position statement regarding
cultural diversity, encouraging school counselors to “foster increased awareness,
understanding and appreciation of cultural diversity in the school and community
through advocacy, networking and resource utilization to ensure a welcoming school
environment” (p. 1).
Despite the ethical mandate and the professional standards, the fact that this
country has become increasingly diverse is a compelling reason for counselors to
become more culturally competent. Becoming knowledgeable about diversity is one
means of doing that. In addition to a strong knowledge base that includes awareness
of various ethnic groups, as well as the acculturation process and identity development models, counseling professionals also need to be aware of their own cultural
backgrounds and understand how diversity will impact the counseling process.
EXAMINING COUNSELOR BIAS
Regardless of whether you are a counseling practitioner or training to be one, exploring your own biases, assumptions, and belief system is a crucial first step in becoming
a multiculturally competent counselor. This exploration can be done in a variety of
ways, such as completing formal assessments like the Counselors Self-Assessment
of Cultural Awareness Scale (Vernon & Clemente, 2005) This scale measures cultural awareness and identifies the areas that may need improvement. In addition
to formal assessments, it is imperative to interact with others who are different and
remain open to these experiences to critically examine personal biases, which may
be hidden. It is important to realize that increasing multicultural competency is a
gradual, developmental process.
Once you have identified your “blind spots” or issues that you need to work on,
you can develop a plan of action. I encourage you to set goals for yourselves by reading and attending activities and events to increase your multicultural competence.
You can also keep a journal describing your thoughts, feelings, and reactions as
you complete these goals, which is a good way to measure growth and change. If
you work with children and adolescents, you may want to consider various ways to
improve your multicultural competency in school or clinical mental health settings
by developing cross-cultural relationships in personal and professional settings,
reading autobiographies written by individuals from diverse backgrounds, opening
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yourself to new learning experiences, attending professional development workshops
that focus on various aspects of multiculturalism, or learning another language.
Read about how to engage in your local community in the “Now Try This!” side bar.
NOW TRY THIS!
Once you have learned about the value systems of various ethnic groups,
volunteer at a school or Boy’s and Girl’s Club. Observe the children’s interactions with each other. What do you notice about their styles of communication? How do they respond to you when you join in an activity with them?
Challenge yourself to talk with them about their family and values while
playing a game.
ACCULTURATION AND ETHNIC
IDENTITY FORMATION
When working with children and adolescents, it is important to consider acculturation issues as well as identity development, as these concepts are often interlinked.
Acculturation refers to how individuals blend their cultural beliefs and practices
with the dominant beliefs and practices of a society. Ethnic identity development
models describe the process individuals experience as they discover their identity
(Robinson-Wood, 2016).
ACCULTURATION
Typically, individuals portray one of four patterns of acculturation: integration (blending of culture of origin and dominant cultural practices); assimilation (replacing
culture of origin practices with the dominant cultural practices); separation (rejecting of dominant culture and retaining culture of origin practices exclusively); and
marginalization (rejecting and separation from both culture of origin and dominant
culture) (Berry, 2006).
Keep in mind that children and adolescents’ patterns of acculturation may be
different than their parents, which may contribute to family conflicts. For example,
children are often placed in situations where they must interpret for their parents,
which impacts the hierarchy in the family and can contribute to family conflicts (Sue
& Sue, 2015). Counselors should avoid putting children in those situations by using
interpreters or learning other languages whenever possible. Notably, adolescents who
have difficulty with the acculturation process are at risk for developing problems
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such as alcohol and nicotine use (Beckstead, Lambert, DuBose, & Lineham, 2015),
somatic complaints (Sirin, Ryce, Gupta, & Rogers-Sirin, 2013), trauma (Bemak &
Chung, 2017), and depression and anxiety (Sirin et al., 2013).
IDENTITY MODELS
Many identity models have been developed to illustrate how healthy racial and cultural
identity develops (Helms, 1995; McAuliffe, 2013; Rivas-Drake, et al., 2014; Sue & Sue,
2015). According to Umana-Taylor and colleagues (2014), ethnic-racial identity development is defined as a “multidimensional, psychological construct that reflects the
beliefs and attitudes that individuals have about their ethnic-racial group membership
as well as the processes by which these beliefs and attitudes develop over time” (p. 23).
Bernal, Knight, Garza, Ocampo, and Cota (1993), as well as Marcia (1980), developed
models most applicable to children and adolescents. The model developed by Bernal
and colleagues (1993) explains the ethnic identity development of Hispanic children
but may be applicable to other minority children’s identity development (Henderson &
Thompson, 2011). In this step-by-step model, children first develop ethnic self-identity
in which they are able to classify themselves within an ethnic group. Next, ethnic
constancy occurs as children recognize that their ethnicity remains consistent over
time and place. Third, children engage in cultural practices, customs, and languages,
which are referred to as ethnic role behavior. Fourth, children exhibit ethnic knowledge, characterized by the recognition that many of their behaviors are important
components of their ethnic heritages and practices. Finally, children develop ethnic
feelings and preferences by expressing emotions and feelings related to their ethnic
group. Understanding these concepts is important to help children learn about their
cultural uniqueness and explore feelings related to their culture.
As children grow and develop, their understanding of their ethnicity also changes
and becomes more meaningful and complex. Marcia (1980) identified ethnic identity
development statuses of adolescents from various ethnic groups. In the first status,
identity diffusion or foreclosure, adolescents have yet to explore their ethnic identity.
During the exploration or moratorium status, adolescents explore their ethnic heritage,
practices, and customs, which eventually enables them to commit to an ethnic identity.
This status is referred to as ethnic identity achievement. Rivas-Drake and colleagues
(2014) note that youth who have a positive ethnic-racial affect have improved social
functioning, self-esteem, well-being, and positive academic attitudes and achievements.
As previously mentioned, the number of youth who identify as multiethnic continues to grow in the United States, so single-ethnicity models may not adequately
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describe many individuals’ process of identity development. Choi-Misailidis (2010)
developed the multiracial heritage awareness and personal affiliations (M-HAPA)
theory, which consists of three identity statuses: marginal, singular, and integrated.
Individuals who identify as marginal tend to lack affiliation with any racial group.
The status of singular refers to individuals who identify with the racial group society
has bestowed on them. Lastly, the integrated status represents individuals who have
both accepted the complexity of their racial identity and integrated this into their
overall self-identity. Individuals whose identity is in the integrated status tend to
have more ethnic pride and positive self-esteem. Although multi-heritage models
have not been researched extensively, it is apparent that there is a need for further
research in this area. (McAuliffe, Grothaus, & Gomez, 2013).
Knowledge of identity development is crucial when working with youth from
diverse backgrounds. Based on the models described, counselors may consider
encouraging children and adolescents to explore their cultural background, as this
may contribute positively to their psychosocial development. If counselors are able
to identify the stage of development, they might be better able to tailor interventions
to meet young clients’ needs (Robinson-Wood, 2016). This knowledge will also be
helpful in promoting ethnic identity. Consider how you might work with the youth
described in the “Voices From the Field” sidebar.
VOICES FROM THE FIELD—A YOUNG CLIENT
Sometimes going to a school where most everyone is White can be hard. Some
kids have made fun of me and called me names. Middle school was really hard
as I felt similar to my classmates, but they saw me as different. Now that I am in
high school, I want others to know about my culture, so I wrote a paper in one of
my classes about how I feel. I think about talking with the school counselor, but I
don’t know if she will understand because she’s White.
—Luang, eighth-grade student of mixed heritage
According to Yip (2013), youth with well-developed ethnic identity spend time
thinking about the role of race and ethnicity in their life and accept that all their
roles are important to the self-concept. These same youth are better able to cope with
difficulties in everyday life, are more self-aware, and have positive feelings about
their ethnic group membership.
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Understanding identity development may also help youth advocate for themselves.
Counselors are in an ideal position to teach advocacy skills and serve as a cultural
translator between minority youth and schools or agencies to ensure that effective
services are provided (Portman, 2009). Astramovich and Harris (2007) outline
self-advocacy competencies to assist minority children and adolescents to succeed
in academic, career, and personal pursuits. These competencies encourage youth
to develop awareness and knowledge of their own culture, understand the impact
of oppression and prejudices, and learn to develop assertiveness and negotiation
skills to use when dealing with barriers to success. Building relations with mentors
and community members to impact change and learning how to use their personal
strengths will help them build a better community. When children and adolescents
are able to advocate for themselves, they become empowered and are better able to
promote their ideas, needs, and rights.
ETHNICALLY DIVERSE CHILDREN
AND ADOLESCENTS
Factors related to working with several ethnically diverse groups are described next.
Each section addresses strengths of the culture, values, typical presenting problems,
and counseling considerations and interventions.
AFRICAN AMERICANS
African Americans comprise 14% of the general populations. (U.S. Bureau of the
Census, 2016), which has slightly increased over the last 10 years. African American
children experience greater rates of poverty than other children. According to the
National Center for Children in Poverty (2014), not only does poverty contribute to
children’s poor physical and mental health, it can also hamper their ability to learn
and may contribute to social, emotional, and behavioral problems. As a result, African
American youth need access to quality counseling services (Owens, Simmons, Bryant,
& Henfield, 2011). Although African Americans have faced considerable racism,
oppression, and discrimination, their community has gained strength as a collective
society and has demonstrated persistence, flexibility, and resilience (Jones, 2014).
Values
When working with clients from diverse backgrounds, the Multicultural and
Social Justice Counseling Competencies encourage counselors to understand their
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clients’ worldview (Ratts, et al. 2015). Traditional African values center around
seven principles of the Nguzo Saba and provide purpose and guidance in one’s life.
These principles include unity (umoja), self-determination (kujichagalia), purpose
(nia), faith (imani), creativity (kuumba), cooperative economics (ujaama), and collective work and responsibility (ujima). According to Robinson-Wood (2016), these
can be used to develop healthy resistance and can be useful in counseling people
from an African background. For example, counselors can support these values
by encouraging youth to express their emotions through art projects or to engage
in community service projects. Another creative intervention for supporting and
encouraging mental health and wellness with African American children is play
therapy, which reduces externalizing behavior and disruption in the classroom
(Stutey, Dunn, Shelnut, & Ryan, 2017). Washington (2018) integrated rap music
into the counseling process with young African American boys and suggested that
counselors working with African American males learn to speak the language of
sociopolitical rap music about the oppression they face. This culturally informed
intervention can interrupt the systemic forces branding African American males
as criminal, while also teaching young men to be agents of educational social
change and social justice. This intervention positively impacts their transition
from adolescence to adulthood, according to Washington.
Family
African Americans tend to place a high value on family. Many African American
families have multiple generations living within the same household, so care and
discipline of the children is often shared among the adults in the home (Evans, 2013).
Because of the strong family ties, counselors should consider involving the family
in the counseling process when feasible. The “Dialogue Box” sidebar provides an
example of how to incorporate family values into a session when family members
are unable to attend.
DIALOGUE BOX
COUNSELOR: What happened after the awards assembly today?
CLIENT: A bunch of kids told me I only received the award because
I am Black.
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COUNSELOR: How did you respond?
CLIENT: I just walked away. I was so proud to receive the award and
then so hurt by what they said. I work really hard to receive good
grades and I work and participate in extra-curricular activities. I get stereotyped whether it is for good or bad. I can’t seem to catch a break.
COUNSELOR: It sounds like you are proud of who you are and all that
you have accomplished. I am wondering how your family and close
friends will react when they hear that you have received this award?
CLIENT: I know they will be proud of me and that my siblings look
up to me, and I want to be a good role model. Also, the coach and
guys on my team will be happy for me.
COUNSELOR: I noticed you started to smile and sit up straight
when you told me about your family and friends’ reactions. How
does that feel?
CLIENT: I feel strong, proud, and smart when I think about their
reactions.
COUNSELOR: I want you to remember this sense of pride and
strength so that when you are faced with negative reactions and
stereotypes in the future you can recall this experience by taking
a deep breath, pulling your shoulders back, and feeling that same
degree of pride you had when you told people close to you about
your accomplishments.
CLIENTS: I think I can do that!
Counselors must also realize that family may extend beyond the nuclear family;
oftentimes, individuals who are close to the family may be considered “family”
even though they may not be blood relatives. Sue and Sue (2015) point out that this
arrangement allows family members to adopt different roles in the family, such as
provider or disciplinarian. Counselors should help the family organize and use this
arrangement and various roles as a strength and asset versus viewing it as a deficit
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that needs to be changed. Using a genogram is also useful in understanding family
roles and relationships.
Presenting Problems of African American Youth
African American youth may seek or be referred for counseling for a variety of
reasons, such as dealing with the adverse effects of stereotypes, racism, and oppression, poor academic achievement, physical developmental differences, and difficulty
developing a high self-esteem and strong African American identity (Baruth &
Manning, 2012). Counselors must also keep in mind that prejudice often contributes to African American youth being “sent” to counseling to be “fixed.” To provide
culturally competent counseling, counselors have to recognize the impact of living
in an oppressive society and how this may contribute to a young client’s presenting
problem (Owens et al., 2011).
Counseling Considerations and Interventions
The following suggestions will help counselors be more culturally sensitive in their
work with African American youth:
1.
Because African American youth tend to be tied to their community, counseling services might be utilized at a higher rate if they are offered in familiar
settings. These youth may receive more mental health services through the
school than community-based mental health centers, so school counselors are
encouraged to offer direct services to African American youth and families
(Owens et al., 2011)
2.
Ross (2016) encourages the use of a strengths-based approach when working
with young African American males to combat some of the impact of negative
stereotypes.
3.
Integrating discussion and reflection on the effects of living in a racist society
is crucial in providing competent counseling for African American youth.
Without this contextual discussion, counseling may not be as effective (Sue
& Sue, 2015).
4.
Counselors must be cautious not to mimic the responses of the majority culture
regarding racism and discrimination and spend considerable time building
trust with African American clients by acknowledging the potential impact
of racism on them (Jones, 2014).
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5.
Cognitive behavioral therapy (CBT) is useful when working with African
American children and adolescents because it empowers young clients to be
experts on themselves and teaches them skills they can use independently,
which is important in the event that they are not able to continue in counseling
in the future (Wilson & Cottone, 2013).
MIDDLE EASTERN AMERICANS
Middle Eastern Americans have become increasingly visible in the counseling literature (Hakim-Larson, Nassar-McMillan, & Paterson, 2013). The American-Arab
Anti-Discrimination Committee (ACD) defines Middle Eastern Americans by their
language, cultural practices, or countries of origin. People from Algeria, Egypt,
Iraq, Kuwait, Lebanon, Libya, Morocco, Oman, Palestine, Qatar, Saudi Arabia,
Somalia, Sudan, Syria, the United Arab Emirates, and Yemen can be included in
this group. The Arab American Institute Foundation (2014) reports approximately
3.6 million Middle Easterners living in the United States from multiple Arab/
Middle Eastern countries, and this number continues to grow (Al Khateeb, Al
Hadidi, & Alkhatib, 2014). As a result, counselors will likely come into contact
with Middle Eastern American youth in schools and clinical mental health settings
(Hakim-Larson et al., 2013).
As a result of the September 11, 2001 attacks on the United States, many new
government policies were put into place that have affected the lives of many Middle
Eastern American youth. Due to the political climate and negative media portrayal
of Middle Eastern Americans, these youth may struggle with acculturation stress, so
counselors must be able to understand the unique challenges of these youth (Goforth,
Pham, Chun, Castro-Olivo, & Yosai, 2016; Soheilian & Inman, 2015).
Values
Although many values that have been associated with Middle Eastern American
families are also rooted in Muslim traditions, not all Middle Eastern Americans
identify as Muslim. In fact, a considerable number practice Christianity and other
religions (Hakim-Larson et al., 2013). Middle Eastern Americans, as a whole, value
generosity, hospitality, prosperity, family honor, hard work, thrift, educational
attainment, and economic advancement. Even though some of these values originated from Muslim practices, many values have been integrated into the cultural
practices of Middle Eastern American families regardless of religious practices
(Hakim-Larson et. al., 2013).
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Family
Loyalty and commitment to family members are high priorities in Middle Eastern
American families. These families tend to be structured in a hierarchical fashion,
with the father typically as the head of the household. The father’s role usually
includes providing economically for the family, acting as disciplinarian, and
helping the family maintain honor, order, cohesiveness, and social standing. The
mother’s role usually includes the education of the children and the running of
the household. The parents typically emphasize collectivist values and teaching
the children to place the family needs before their individual needs (Alkhateeb,
2010). In Middle Eastern American families, children are allowed and encouraged to express their emotions, and child-rearing practices in traditional Middle
Eastern American families instill behaviors orientated toward interdependence
versus autonomy and independence. These roles and communication patterns
within families are essential to understand when working with Middle Eastern
American youth (Hakim-Larson et. al.,2013).
Presenting Problems of Middle Eastern American Youth
Children in Middle Eastern American families are often expected to respect their
elders and play a more subservient role in the family unit. Adolescents may complain about lack of privacy due to the often tight-knit community of Middle Eastern
Americans, but this community support can also be a protective factor related to
mental health problems (Basit & Hamid, 2010). Hakim-Larson and colleagues
(2013) also note that many Middle Eastern children and adolescents immigrating
from war-torn countries may have Post-Traumatic Stress Disorder, which may
look like Attention Deficit/Hyperactivity Disorder or other behavioral disorders.
Counselors must take trauma into consideration when completing a thorough,
contextual assessment.
Middle Eastern Americans tend to present with more somatic complaints and
have a very high tolerance for emotional suffering and pain. Some Middle Eastern Americans believe that emotional problems have a spiritual or evil basis, so
counselors should consider this in treatment and not pathologize the behavior.
For example, Nassar-McMillan and Hakim-Larson (2003) described working
with a Middle Eastern client who was having trouble sleeping. After the counselor
inquired about cultural traditions or rituals that might help her sleep, the client
shared that she sprinkled salt outside of her door to ward off evil spirits. The culturally competent counselor supported this practice and encouraged the client to
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use this technique, which continued to be beneficial. This example illustrates the
importance of discussing cultural practices and how they might be integrated
into counseling.
Counseling Considerations and Interventions
The following suggestions will facilitate the counseling process with Middle Eastern
American children and adolescents:
1.
Middle Eastern Americans have a tremendous amount of economic, social,
religious, educational, and acculturative differences within their cultural
groups. Counselors must be aware of their own biases and understand the
complexity of Middle Eastern youths’ self-identities (Al Khateeb, Al Hadidi,
& Alkhatib, 2014).
2.
Counselors must consider youth’s level of acculturation and reasons for immigration because these factors can impact young clients significantly and be
important in framing the presenting problems (Goforth, et al., 2016).
3.
Counselors must consider the amount of stigma still present in the Middle
Eastern American community regarding seeking mental health services.
Goal-directed and concrete interventions must be used during the initial
sessions, as many Middle Eastern American clients will expect to leave the
first session with some concrete suggestions. This may aid in client retention
(Ciftci, Jones, & Corrigan, 2012).
4.
Because family is highly valued in Middle Eastern families, it is crucial that the
family be involved when counseling children and adolescents. In schools, the
counselor might want to develop relationships with the family outside formal
counseling sessions by asking them to volunteer or to assist in a guidance
lesson on diversity.
5.
Counselors should engage in outreach and advocacy activities, which will provide opportunities to learn about culture and build relationships with leaders
in the Middle Eastern communities.
ASIAN AMERICAN AND PACIFIC ISLAND YOUTH
Asian American youth can include individuals who identify from a variety of backgrounds such as Chinese, Japanese, Korean, Filipino, Vietnamese, Cambodian,
Thai, Hmong, Laotian, and Samoan (Sue & Sue, 2015). Asian Americans and Pacific
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Islanders comprise 6% of the general population, and, by 2050, approximately 1 in 10
people living in the United States will be able to trace their heritage to one of the Asian
Cultures (United States Census Bureau, 2016). Asian Americans are characterized by
a strong sense of humanity, interpersonal harmony in relationships, and benevolence.
Values
Asian American families are generally described as reserved, constrained, and
exhibiting emotional self-control. As a group, they tend to be a collective society
and value group interest over individual interests. Children are taught obedience to
authority and are very conscious of saving face for the family as well as for themselves (Sue & Sue, 2015). Robinson-Wood (2016) also notes that the values of Yuan
(influence of past relationships on present social relationships) and Ren Qing (social
favors exchanged in the form of money, goods, information) are important to be
aware of when working with Asian American youth.
Family
Asian families are characterized as collectivistic. Their parenting practices reinforce
cultural values of cohesion, unity, and avoidance of shame (Lui & Rollock, 2013).
Asian families are arranged in a paternal hierarchy in which men and the elderly hold
the highest status. In some Asian American families, parents stress the importance
of intellectual and academic achievement and competency (Lui & Rollock, 2013). In
addition, there are some within-group differences regarding parental approach. For
example, Japanese and Filipino families approach parenting from a more egalitarian
perspective, while parents from Korea, China, and Southeast Asia tend to be more
authoritarian (Van Campen & Russell, 2011). When assessing Asian American
children and their families, counselors must do so carefully within a family and
community context.
Presenting Problems of Asian American Youth
Typically, Asian American youth have similar problems to those of other minority
youth, such as struggling with the differences in values between what is reinforced
in schools versus what is reinforced at home, as well as difficulties with language
differences (especially when families have recently immigrated). Because most Asian
American families highly value academic achievement, youth who are struggling
may seek counseling for academic and career issues rather than for emotional concerns (Brammer, 2012).
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Her (2016) describes several counseling considerations when working with Hmong
children. When Hmong people immigrated to the United States, many were relocated throughout the United States. This negatively impacted families because this is
a close, collective society. Consequently, children from this culture may present with
symptoms related to post traumatic stress and acculturation-related issues. When
working with children and adolescents from the Hmong culture, Her (2016) suggests
becoming knowledgeable about cultural practice, using a problem-solving approach,
and developing culturally sensitive practices in mental health and schools settings.
Sandtray therapy—or Hakoniwa, as it is referred to in the Japanese culture,—may
be another useful intervention when working with Asian children, especially youth
from Japan. Hakoniwa involves placing various figurines and miniatures in a shallow
tray of sand, illustrating the child’s inner world. This technique is ideal because it
allows young clients to communicate nonverbally, encourages therapeutic work in the
“here and now,” and can be a relaxing intervention for youth (Enns & Kasai , 2017).
Counseling Considerations and Interventions
The following suggestions can be beneficial to counselors working with Asian
American youth:
1.
Asian adolescents often present with acculturation difficulties such as conflicts with parents and struggling between autonomy and interdependence.
Counselors may want to ask how their family views these conflicts and help
them balance between their needs and their family’s needs (Sue & Sue, 2015).
2.
Counselors must understand the common religious practices of the Asian youth
they are working with in counseling. This knowledge can assist in building a
stronger therapeutic relationship with the child as well as the family (Farah,
Multani, Hynie, Shakya, & McKenzie, 2017).
3.
Many Asian families focus on academic achievement and success of their
children. Counselors may want to help parents identify other positive behaviors and contributions of their children, especially when they are struggling
academically (Sue & Sue, 2015).
4.
Asian Americans are often referred to as the “model minority,” which assumes
that they always function well, are exempt from cultural conflicts and discrimination, and experience few adjustment difficulties. Counselors need to be aware
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that this stereotype tends to create a great deal of stress for Asian youth and
may make them more susceptible to mental health issues (Kim & Park, 2013).
5.
Tai Chi and meditation may be particularly helpful to integrate into counseling
due to familiarity within Asian traditions. It can help improve physiological,
neurological, and psychological health of youth (Posadzki & Jacques, 2017).
LATINOS/AS
Latino/a youth comprise 18% of the general population in the United States and
may identify as Puerto Rican, Cuban, Mexican, or other Latin heritage. This one
of the largest growing minority populations (United States Census Bureau, 2016).
Hence, counselors’ caseloads will more than likely include more and more Latino/a
youth. Although Latinos have some within-group differences, the common Spanish
language is a unifying factor. Counselors will need to inquire about within-group
differences when working with these youth, because when Latino/a children and
adolescents feel culturally understood and empowered, they are better equipped to
reach academic and career goals (Padilla & Hipolito-Delgado, 2015).
Values
Values that have been associated with Latinos/as include faith in family and friends
(familism), respect (respecto), trust in others (confianza), and being a nice and gentle
person (simpatia) (Robinson-Wood, 2016). Counselors should keep these factors in
mind when working with children and families because they are essential in building
strong trusting, therapeutic relationships.
Family
Latinos/as place a high value on family. According to Barker, Cook, and Borrego
(2010), familism encourages a combination of collectivism and interdependence.
Multiple generations often live within one household, especially families who have
recently immigrated to the United States. In addition, families often share resources
and possessions that they own collectively. Children may refer to the weekly family
meal or la comida seminal as a time when families join together and bond. This
may provide a good source of support to Latino/a youth and serve as a protective
factor. Children and adolescents who attend predominately non-Latino schools may
especially value la comida seminal because it provides an important connection to
family members and gives them an opportunity to speak Spanish and share concerns
with people who can relate to their struggles (Brammer, 2012).
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Presenting Problems of Latino/a Youth
Villalba, Brunelli, Lewis, and Orfanedes (2007) interviewed Latino/a parents, who
indicated that their children experienced stress and transition problems in the
public-school system. In addition, parents had difficulty dealing with inappropriate expectations of their children’s behaviors and academic performance. Also, the
parents expressed that some schools were “cold,” in contrast to their cultural value
of being warm and caring (personlismo).
Latino/a children and adolescents may develop psychosocial difficulties resulting
from poverty, language barriers, and discrimination. Also, language barriers may
contribute to a misunderstanding of counseling services provided by schools and
mental health agencies, as well as cause difficulties navigating these systems. The need
for Spanish-speaking counselors is great and could increase the use of counseling
services by non-English speaking clients. Speaking someone’s native language can
foster strong therapeutic relationships and result in more accurate problem assessment (Alegria et al., 2014).
Many Latino/a children and adolescents learn English as their second language.
This sometimes is associated with problems in school adjustment, depression, anxiety, and chronic stress (Isasi, Pastogi, & Molina, 2016). When counselors are able to
adapt their interventions by adding visual aids, culturally relevant metaphors, and
incorporate values and proverbs related to the Latino culture, counseling is more
effective (Alegria, et al., 2014). Refer to the “Voices From the Field” sidebar to learn
how a school embraced culturally competent skills and interventions.
VOICES FROM THE FIELD—A PROFESSIONAL
Due to the influx of immigration of many Latino families to our school district, we
had to examine our counseling services and the ways in which we were providing
those services to our students. We needed to learn different ways to connect
with these youth and respond to their needs. I learned to reach out to parents
and leaders in the immigrant and Latino community to answer my questions,
brainstorm new services I could provide, and learn about resources. Overall, our
district is thriving, but we had to address our own biases. We attended trainings
to learn more about cultural responsive counseling skills and changed the way we
operated as a counseling unit.
—Kayla, high school counselor
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Cuento therapy is an effective intervention for Latino/a youth because it uses
culturally relevant folktales to convey messages about values, beliefs, and healthy
behavior (Ramirez, Jain, Flores-Torres, Perez, & Carlson, 2009). Using stories and
characters from a child’s culture make counseling more relevant to them and more
aligned with their worldview. According to Ramirez and colleagues (2009), this
therapy positively impacts children’s self-esteem, decreases anxiety, and improves
reading scores.
Counseling Considerations and Interventions
The following suggestions may facilitate the counseling process with Latino/
Latina youth:
1.
According to Bernal and Domenech-Rodriguez (2012), parents indicate that
their children are academically and emotionally more successful in environments where counselors are mindful of cultural values and provide culturally
relevant counseling.
2.
Counselors should consider providing services in Spanish when needed,
and school and mental health administrators should consider hiring
Spanish-speaking counselors.
3.
When working with Latino/a clients, counselors should consider the personalismo (intimacy). This can be accomplished by extending a warm greeting and
spending time engaging in small talk about family and daily events, which will
contribute to building rapport and trust with clients (Robinson-Wood, 2016).
4.
Latino/a children benefit from counseling, which helps build their sociocultural awareness, as well as social action and advocacy skills (Padilla &
Hipolito-Delgado, 2015).
5.
Counselors need to remember that sense of time for Latino/a youth is different
from the norm in schools. If they are late for counseling sessions, this may be
the reason (Brammer, 2012).
NATIVE AMERICAN YOUTH
Native American youth compose 1% of public school enrollment. Native American
children represent the largest portion of the Native American community (United
States Census Bureau, 2016). Although statistics often group all Native Americans
into one category, counselors need to be aware that Native Americans belong to a
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variety of tribes, bands, and clans. Therefore, it is important to inquire about specific
group affiliation, as many within-group differences exist.
Various levels of acculturation exist among Native American youth (Brammer,
2012). When working with Native American children and adolescents, counselors
should ask about their specific cultural practices, such healing rituals or ceremonies,
as well as feelings associated with these practices, to gain insight into the child’s
cultural environment and acculturation level.
Values
Among the values associated with Native American groups are sharing, noninterference, present time orientation, harmony with others, humility, patience, and
generosity (Garrett, et al., 2013). The circle of life, a central component in the Native
American culture and cultural practices, illustrates that all things are connected,
have a purpose, and are worthy of respect. These concepts are threaded throughout
most Native American communities and cultural practices (Garrett, et al., 2014).
Family
Respect for elders is instilled in Native American youth. Elders convey oral histories
and traditions to the younger members of their families and tribe. This culture places
a high value on the sacredness of their youth, encourages them to be self-sufficient,
and believes they are central to the health and wellness in a community (Sarche &
Whitesell, 2012).
Presenting Problems of Native American Youth
Native American youth present with a variety of problems related to forced assimilation of their parents and grandparents and a lack of recognition as a minority by
many people. Baruth and Manning (2012) note that Native American children may
have difficulties developing a strong cultural identity and positive self-concept. Some
may also have poor English proficiency, feel misunderstood due to the nonverbal
communication patterns in Native American culture, and have lower academic
achievement than their non-Native American counterparts. Adolescent problems
tend to revolve around acculturation issues and the adverse effect of being misunderstood by non-Native American school personnel. According to Hunter and
Sawyer (2006), there are numerous interventions that reinforce values associated
with Native Americans’ community. One intervention they describe is the “earth’s
gift” (Hunter & Sawyer, 2006, p. 245), in which a child is asked to find a special object
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from nature and bring it to a session. The child then tells why he or she chose the
object and what makes it special. This activity reinforces the connection between
Native American youth and Mother Earth and reminds them to be thankful for the
other gifts they receive from nature.
Counseling Considerations and Interventions
The following information should prove useful in counseling Native American youth:
1.
Native Americans tend to be more in tune with the earth’s natural rhythms
and take their cues from nature (i.e., sunrise) regarding time. They tend to
see the beginning and end of an activity as depending on the activity and not
according to the time on a clock (Garrett et al., 2014).
2.
Underlying grief issues have to be considered when working with Native American youth because of the high rates of suicide, alcohol use, and other health-related
problems within Native American communities (Gilder, et al., 2017).
3.
As a result of historical events, some Native Americans distrust European
American professionals, so counselors have to spend time building rapport
with Native American youth (Baruth & Manning, 2012).
4.
Brammer (2012) suggests that counselors must become knowledgeable about
cultural practices and value systems such as limiting eye contact, slowing the
pace of the conversation, and not interrupting the client.
IMMIGRANTS
An increasing number of youth are significantly impacted by immigration to the
United States. In fact, the percentage of immigrant children grew from 18 to 25%
between 1994 and 2014 (Child Trends, 2014). In urban areas, more than half of the
students who may seek counseling services in schools and mental health agencies
are immigrants from a variety of countries. These youth may present with problems
related to trauma, disrupted family relationships and support, or they may experience
challenges due to financial stress and lack of resources (Sirin et al., 2013).
ACCULTURATION
When youth immigrate to the United States, they may experience acculturation
struggles. As previously noted, the acculturation process occurs when immigrants
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begin to operate within the dominant culture. Acculturation stress arises when the
demands exceed the internal and external recourses needed to meet the needs of
daily living (Berry, 2006). During the immigration process, immigrant children and
adolescents may also experience discrimination, communication difficulties, guilt, or
shifting gender roles, all of which add to their stress level (Sandhu & Madathil, 2013).
Counselors must be aware of the additional difficulties immigrant youth encounter,
help them develop coping skills, and provide resources to them and their families.
ADVOCACY
Counselors also need to advocate for the unique needs of immigrant youth within
the school system and the community and must be familiar with immigration
policies and resources. Connecting families in the community is also crucial. For
example, over the last several years in my Midwestern community there are many
families who have immigrated from Myanmar (Burma). Due to the various dialects
that are spoken by these newcomers, communication within and outside the community has been difficult, which has put them at risk for even further isolation. A
school counseling student and I, both avid knitters, decided to join efforts with a
local social service agency to start a knitting group. Many women from this culture
weave beautiful tapestries and many no longer have access to the necessary tools.
The knitting group was designed to bring women of all ages together, and this
intergenerational group grew quickly. A sense of community developed in the group
through an activity that transcended spoken language and connected them to their
native practices. The young women in the group connected with their mothers and
grandmothers through something that was familiar to them, and we connected
these young women with resources in the community and provided information
to help them transition to a new school environment.
COUNSELING CONSIDERATIONS AND INTERVENTIONS
The following information should prove useful in counseling immigrant youth:
1.
Counselors should consider using client-centered play therapy when working
with immigrant children because this approach sets boundaries and rules for
safety, which is particularly helpful for this population. Play therapy can be
adapted to a variety of cultures by selecting relevant play therapy materials,
and this approach also reduces the need to use spoken language (Killian,
Cardona, & Hudspeth, 2017)
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2.
Bemak & Chung (2017) suggest using interventions that integrate culturally
responsive Western psychotherapy with indigenous healing methods, cultural
empowerment, and psychosocial interventions to address the needs of immigrants.
3.
Counselors should be aware that adolescents who have difficulty with acculturation may not be exhibiting overt behaviors, but often internalize their
problems and present with symptoms associated with anxiety or depression.
Since these symptoms are often times less likely to be noticed by parents and
teachers, providing outreach and information to parents, schools, and community agencies would be helpful (Sirin et al., 2013).
4.
Although for many families the process of immigration can result in opportunity, there is considerable stress and loss involved in the process, with significant
implications for the psychological development and identity formation of
immigrant youth (Coll & Marks, 2009).
GENDER
Gender is a very significant variable that counselors must consider when working
with children and adolescents. Gender roles and expectations are not only influenced
by society, but also by culture, family, and spiritual practices. Some general gender
issues warrant mentioning when working with youth, including gender identity
and awareness, gender socialization, and counseling considerations. Failure to
recognize important gender differences has resulted in substantial harm to youth
over the years (Sax, 2017).
GENDER AWARENESS AND IDENTITY
Gender identity development is crucial to understand when working with youth
and is an interactive process involving cognitive, social, and biological processes.
According to Signorella (2012), when children are approximately 2 to 3 years old,
they are able to identify their gender based on physical characteristics only. Then,
sometime between 4 and 5 years old, children start to realize that their gender
remains consistent. By 6 years of age, children realize that gender is consistent across
time and situations. Social learning theory adds to the understanding of gender
development and posits that gender-typed behavior is learned through social interactions, which contributes to gender identity (Eagly, 2001). Gender is complicated
and multifaceted and counselors must understand the biological, social, and political
influences regarding gender development and how that impacts young clients. Read
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about an intervention that helps youth explore gender identity in the “Add This to
Your Toolbox” sidebar.
ADD THIS TO YOUR TOOLBOX
Since youth are avid users of technology, I like to incorporate it into sessions as a way of engaging them in the counseling process. Over the course
of 1 week, I have them take pictures relating to gender. I leave it open ended for them to define it beyond that. If students do not have a smart phone,
I give them a disposable camera. The results provide amazing insight into
how they view their gender identity. The conversations from these pictures
often continue throughout my work with these clients. This intervention can
be used individually or in small groups and classroom sessions.
Although the majority of counselors work with youth who identify as cisgender
male or cisgender female, it is important to note that some may not fit into either
category and they might identify using terms such as transgender, gender variant,
non-binary, non-conforming, or other similar terms. Counselors should be aware
and knowledgeable of the various gender labels, keep current with regard to terminology, and remain sensitive to the ever-evolving gender expectations.
Black, Crethar, Dermer, and Luke (2007) suggest defining gender on a continuum rather than as two distinct categories to provide a more accurate reflection of
all youth and to be more inclusive in terms of diversity. When counselors simply
acknowledge that gender identity in non-binary, it allows young clients who struggle
with gender identity to share their thoughts and feelings.
GENDER SOCIALIZATION
Children are socialized in their gender roles very early in life. This socialization
is influenced in many ways by parents, teachers, family members, and the media,
including television, books, and the Internet.
In an important historical study, Gilligan (1990) found girls to have higher levels of
self-esteem, exhibit more confidence in their abilities, and be more optimistic about the
future at age 9, but these positive beliefs and traits decline as they reach their adolescent
years. Gilligan also found that relationships were crucial in young girls’ development.
Over the last 30 years, positive progress appears to have been made, as Agawri and Puri
(2017) found adolescent girls to be happy and better adjusted in school than previous
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research had indicated. Sax (2017) suggests that girls’ strong bonds with one another
help them to feel more comfortable in school, which positively impacts their performance. When young females come to counseling, they often reveal problems related
to body image, sexuality, relationships, and victimization (Baruth & Manning, 2012).
They are also at higher risk than boys for alcohol abuse and eating disorders (Sax, 2017).
Boys are also socialized into roles that at times are more harmful than helpful.
Boys are encouraged to be assertive, to feel superior to women, and to be self-reliant. They are also taught to restrict their emotions, act tough, and avoid all things
feminine (often referred to as “boy code” (Blazina, 2004, p. 152,). As a result, boys
tend to have great difficulty expressing emotions other than anger and have more
difficulty adjusting to school when compared to girls (Agawri & Puri, 2017). Boys
and young men often present to counselors with more externalizing problems such
as aggression, attention-seeking behavior, and substance abuse issues (Baruth &
Manning, 2012). Boys also are at risk for poor academic performance (Sax, 2017).
COUNSELING CONSIDERATIONS AND INTERVENTIONS
Effective things counselors can do when working with gender issues include
the following:
1.
Avoid gender stereotypes when working with youth because these can contribute to misdiagnosis and treatment of young boys and girls (Baruth &
Manning, 2012).
2.
Consider using girl-only or boy-only group work, as research has shown that
children excel when information and approaches are tailored toward their
gender preferences and differences (Sax, 2017).
3.
Girls often spend time in face-to-face conversations and interactions and tend
to spend their time sharing secrets, personal doubts, and difficulties with
friends. In contrast, boys spend time in shoulder-to-shoulder activities such
as playing video games and engaging in physical activities. When counselors
choose interventions and activities, they want to consider these factors and
incorporate appropriate interventions. Counselors may also suggest that teachers work with young girls face to face and with boys side by side (Sax, 2017).
4.
Nondirective play therapy may be used with gender variant children, as it
fosters acceptance, which may facilitate young children to explore their gender
identity (Landreth, 2012).
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5.
When working with gender variant children, family therapy may help family
members cope with the ambiguity and learn to communicate more openly. It
can also help them combat feelings of isolation (Black et al., 2007).
SPIRITUALITY AND RELIGION
Spirituality and religion can play an important role when working with children.
Although many children and adolescents are raised within a faith tradition, the
largest growing group globally, roughly 1 in 6 people (just over 16%) have no
religious affiliation (Cooperman, Smith, & Ritchey, 2015). This equates to approximately one in six people and makes the unaffiliated the third largest “religious”
group worldwide. Although a large number of religious and spiritual practices exist,
it is beyond the scope of this chapter to cover more than these widely practiced,
but less dominant practices: Judaism, Buddhism, Islam, and Hinduism. The Competencies for Integrating Spirituality into Counseling created by the Association
for Spiritual, Ethical, and Religious Values in Counseling (ASERVIC) should be
considered when incorporating aspects of a client’s faith practices (Cashwell &
Watts, 2010).
JUDAISM
Judaism goes beyond religion and has also been referred to as culture, ethnicity, and
a set of traditions. It is estimated that approximately 14 million people practice the
Jewish faith worldwide, and they usually belong to one of three groups: Orthodox,
Reformed, or Conservative. Group affiliations affect how individuals practice their
faith, so counselors need to inquire about these differences to provide competent
care. For example, Jewish children and adolescents may follow dietary restrictions,
celebrate holidays many school districts do not recognize, and may encounter acts
of anti-Semitism. Some youth wear small head coverings called yamakas, and classmates might ridicule them or try to remove the yamaka (Smith, 2004). According
to James, Lester, and Brooks (2012), parents who model Judaism are more likely to
have children who follow the faith and cultural practices.
ISLAM
Approximately 1.3 billion individuals worldwide practice Islam, whose faith practices are based on the following five pillars of faith: (1) The belief that there is only
one God and Muhammad is his messenger; (2) one should pray five times daily
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at predetermined times; (3) individuals are encouraged to give to the poor; (4) A
person should fast during Ramadan; and (5) if possible, individuals should make a
pilgrimage to the Mecca. Youth practicing the Islamic religion may follow dietary
restrictions and fast during certain times of the year, wear traditional dress, and
pray throughout the day (Hakim-Larson, Nassar-McMillan, and Paterson, 2013).
HINDUISM
Approximately 900 million people worldwide in various cultures practice Hinduism
(Cooperman, Smith, & Ritchey, 2015). People of the Hindi faith believe in multiple
deities, and the concept of karma is a central component of Hinduism. Hindis often
practice yoga and meditation to transcend into the spiritual realm. Most families
that practice Hinduism have a spiritual teacher or guru who works like a counselor.
When working with Hindi youth, counselors may want to incorporate spiritual
practices, such as meditation, into counseling sessions (Hanna & Green, 2004).
BUDDHISM
Buddhism is practiced by 375 million individuals worldwide and focuses on the
end of suffering and producing a sense of liberation (Cooperman, Smith, & Ritchey,
2015). Buddhism is based on the four noble truths, which explore suffering: that
human suffering exists (Dukkha), that there is a cause for the suffering (Samudaya),
that suffering will end (Nirodha), and that one must follow specific practices to end
the suffering (Magga) (Smith, 2004). Many Buddhist practices, such as meditation
and mindfulness, are already practiced by counselors.
Teens define their identity as Buddhist in relation to how often they perform
Buddhist practices, such as meditation and chanting, rather than solely on belief.
Counselors working with Buddhist adolescents must understand how strongly they
practice their faith and how it impacts their actions (Thanissara, 2014).
COUNSELING CONSIDERATIONS AND INTERVENTIONS
The faith practices of children and adolescents provide many benefits, such as an
extended social network of friends. Difficulties that children and adolescents face
regarding their faith and faith practices have more to do with practicing their religion
in a society dominated by Christian beliefs and practices. For example, youth may
be required to attend school on their religious holidays or make crafts and projects
in schools that don’t incorporate their religious beliefs. Counselors can examine
their own belief system by referring to the “Personal Reflection” sidebar.
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PERSONAL REFLECTION
As you learn about various religious and spiritual practices and culturally
competent counseling, it is essential that you spend time reflecting on your
own bias and developing your self-awareness. Challenge yourself to attend
more cultural, religious, or spiritual events in your community, then journal
about your experiences. How did it feel to be in an unfamiliar setting? What
was most challenging? How can you use this experience to inform your
counseling practices?
Counselors may also consider the following:
1.
Counselors should educate themselves about various religious and spiritual
practices and belief systems and consider attending religious or spiritual events
different from their own practices. It is also helpful to become familiar with
religious and spiritual leaders in the community (Vieten et al., 2013).
2.
School counselors can develop a calendar of the religious holidays observed by
various faiths. This demonstrates sensitivity to these faiths and serves as a resource
for faculty and staff in planning school events (Kimbel & Schellenberg, 2014).
3.
Counselors should understand and use the ACSERVIC competencies when integrating religion and spiritual practices into their work with youth (Cashwell &
Watts, 2010).
4.
School counselors should learn about what accommodations can be made
for students who engage in their religious practices at school, such as dietary
restrictions or time for prayer, as well as how to make these accommodations
(Kimbel & Schellenberg, 2014).
5.
Counselors must remember that all family members may not practice the
same religion or have the same spiritual belief system.
COUNSELING INTERVENTIONS
WITH DIVERSE YOUTH
There are many culturally appropriate interventions that have proven effective
when working with children and adolescents from diverse cultures. Because youth
are influenced by their numerous identities (e.g., ethnicity, gender, religious), some
general interventions merit review.
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CREATIVE ARTS
As discussed in chapter 3, creative arts interventions are ideal when counseling
diverse youth. They assist clients in communicating their thoughts, feelings, and
behaviors and are particularly helpful when language barriers exist (Vernon & Barry,
2013). The creative arts are present in one form or another in all cultures and can
be used to help clients and counselors transcend their differences. One activity I
have used individually and in small groups is called “Who Am I.” I give children an
outline of a person and allow them to create their cultural self, using any of the art
supplies. When they have completed this, we discuss how the creation represents the
child’s cultural self. Other culturally appropriate creative arts interventions include
encouraging clients to draw or paint their dreams, design a t-shirt with their family
slogan, or create an art piece that depicts their values, culture, or religion.
MUSIC
Music is another culturally inclusive approach. An effective strategy is to compile
an electronic music library or playlist using Spotify or iTunes that represent various
cultures, and clients can select which songs best represent them and their culture.
This intervention is usually very engaging for young clients.
TECHNOLOGY
Technology has become an inevitable part of everyday life that counselors can integrate into their counseling work with diverse youth (Gladding, 2016). Although not
all children and adolescents have open access to the Internet, most do use technology
in some form. Since they are usually very comfortable with technology, counselors
can invite students to lead them on a “social media tour,” sharing their favorite
websites, YouTube channels, and social media accounts. This is an excellent way to
learn more about the client’s world. I often ask clients what values are important
and if they portray these on their social media accounts.
PLAY THERAPY
Play can be considered the native language of all children and is extremely effective
with young clients, as discussed in chapter 4. Adlerian play therapy may be particularly helpful for diverse youth as it allows clients to gain a better understanding
of themselves, others, and the world. When counselors accompany them on this
journey, they learn how client’s values and culture impact their sense of self and the
world (Kottman & Meany-Walen, 2016). As discussed in chapter 4, counselors must
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be mindful of diversity and include figurines that represent a variety of ethnicities,
genders, religions, and cultures. The use of animal figurines can also be helpful
because they are considered as gender neutral. When clients have access to culturally sensitive items, they are able to explore and express these aspects of themselves.
STORYTELLING AND BIBLIOTHERAPY
Using stories/books (bibliotherapy) or the writing of stories (scriptotherapy) allows
culturally diverse clients to explore and establish their identity (Gladding, 2016). One
of my favorite ways to learn about my clients’ cultures is to ask them to tell me an
interesting story about their family. By listening, I learn about young clients’ levels
of self and cultural awareness, individual and family values, and other contextual
factors. Counselors can also give children various prompts to help them create stories
of success or empowerment, for example, (a) “The little girl felt confident when …”;
and (b) “A family learns a very important lesson when … .” The counselor can listen
for themes, inquire about the reaction of characters, or offer observations about the
interactions between the characters.
PHOTOTHERAPY
Phototherapy encourages clients to capture or express emotions in a visual format.
Counselors can use photos in a variety of ways to assist clients in exploring their
values and belief systems (Gladding, 2016). Counselors can give clients a set of pictures
and ask them to select photos that represent their values, culture, spiritual practices,
or identity. I like to ask youth to show me pictures from their phones that represent
the same categories. These photos can be meaningful and are a bit more personal.
In addition, clients can be asked to create a collage using a variety of photos that
represent themselves. These interventions open the door for clients to explore their
identity and values as they grow and develop.
TAKE-AWAYS FROM CHAPTER 9
As I conclude this chapter, I would like to refer to the short vignette at the beginning
of the chapter and share what I learned from working with this client, as well as a
technique I used that I think was effective. I learned that to be an effective culturally
competent counselor I needed to consider the client’s identity development to choose
appropriate interventions. One strategy I found particularly helpful was using creative
arts interventions. Once I showed interest in Ayala’s artwork depicting her Jewish
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religion and culture, she was much more receptive to the counseling process. We
processed how it was for her to share that part of her identity with someone like me
who isn’t Jewish, which created an opportunity to discuss our religious differences
and more about how she identifies with her beliefs and values.
After reading this chapter you should now be more knowledgeable regarding
these key points:
•
Acculturation and ethnic identity formation
•
Values, family dynamics, and common presenting problems for various ethnic
groups
•
Current challenges of immigrant youth and ways to advocate for them
•
The complexity of gender
•
Religious practices of Judaism, Hinduism, Buddhism, and Islam
•
Identification of culturally relevant interventions and practices
HELPFUL WEBSITES
U.S. Department of Health and Human Services (HHS). Cultural Competence
https://www.hhs.gov/ash/oah/resources-and-training/
tpp-andpdf-resources/cultural-competence/index.html
Diversity and Cultural Resources—EWU
https://access.ewu.edu/caps/selfhelp/diversity-resources
The Trevor Project—Trans + Gender Identity
https://www.thetrevorproject.org/trvr_support_center/
trans-gender-identity/#sm.00000yl17mjbsdd0gyo8fwm2ogsqo
Unitarian Universalist Association (UUA) –Resources about Gender Identity
https://www.uua.org/youth/identity-formation/identity-based/queer/
gender-resources
PRACTICAL RESOURCES
Ratts, M. J., Singh, A. A., Nassar-McMillan, S., Butler, S. K., & McCullough,
J. R. (2015). Multicultural and Social Justice Counseling Competencies.
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pdf?sfvrsn=8573422c_20
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Cole, E. M., & Valentine, D. P. (2000). Multiethnic children portrayed in children’s picture books. Child and Adolescent Social Work Journal, 17(4),
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Roehlkepartain, E.C. (2006). The handbook of spiritual development in childhood and adolescence. Los Angeles, CA: SAGE.
Swazo, R. (2013). The bilingual counselor’s guide to Spanish: Basic vocabulary and interventions for the non-Spanish speaker. New York, NY:
Routledge.
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CHAPTER 10
Children and Challenges
Counseling from a Growth Mind-set Perspective
Monica Leppma & Christine J. Schimmel
(with contributions by Anna Simmons)
LEARNING OBJECTIVES
1.
To describe the concept of resilience in children and adolescents
2.
To recognize the difference between a growth mind-set and a fixed mind-set
3.
To identify serious challenges that some children and adolescents experience and interventions for working on these issues from a growth mind-set
perspective
O
liver, age 10, initially was brought to counseling because he had struggled
with eating issues since he was a toddler. For years, Oliver’s parents had
tried to find answers to explain his limited ability to eat a variety of foods.
The family had consulted with numerous professionals who concluded that he was
stubborn, defiant, or just a finicky eater. However, Oliver’s parents felt that there was
much more to the story regarding his eating habits. For example, he had never eaten
a bite of his own birthday cake, nor had he ever tasted pizza or ice cream—foods
that most pre-teens love. At the time of his first visit with me (Chris), Oliver had a
list of about 10 foods he would eat, as long as they were prepared “correctly” and if
they were the brands that were familiar to him. In this first session, approximately
five sessions into the counseling process, Oliver related that he was discouraged
because most the friends in his social group were now unavailable to hang out
because they were all involved in the local youth basketball league. When asked
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why he didn’t play organized basketball with his friends, the exchange between
Oliver and me went like this:
COUNSELOR: So you don’t play youth basketball with your friends because
you don’t like basketball?
OLIVER: No, I love basketball.
COUNSELOR: So if you love basketball, can you help me understand why
you aren’t playing?
OLIVER: I would like to play, but it’s just that I wouldn’t be any good.
COUNSELOR: Oh, so you have played before and you were not very good at it?
OLIVER: No, I’ve never played. I just know that I wouldn’t be very good.
When children are impacted by extreme picky eating, or even the more severe
sensory food aversion, they often feel as if they cannot excel at anything because
eating, something that should come easily to everyone, is such a challenge. I could
see very quickly that Oliver’s fixed mind-set regarding his ability to do things well
was getting in his way of doing something that he really wanted to try. In turn, his
decision not to try to play was creating a divide between him and his friends, which
made him pretty sad. My “go-to” approach in this case would historically have been
to try using rational emotive behavior therapy (REBT) with Oliver, but I thought
he might need a more concrete intervention to shift to a growth mind-set about
himself, his eating, and about playing basketball.
In an attempt to shift Oliver from a fixed mind-set to a growth mind-set and
challenge his self-talk, I asked Oliver to take a standard tape measure and stretch
it out to the number on the tape measure that he thought was equal to how long he
might live. Oliver promptly stretched the tape measure out to 78 and placed it on
the floor. Check out the “Dialogue Box” sidebar to read how this session progressed.
DIALOGUE BOX
COUNSELOR: Come stand at 10 (as in 10 years old). Look down at
78 (years old). I’m afraid you will get to 78 and be sad because you
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wanted to try new things, but since eating was tough for you, you
assumed everything would be difficult. So, are you thinking that just
because you aren’t able to eat like your friends that you won’t be
good at anything, so you just won’t try?
OLIVER: Maybe.
COUNSELOR: A counselor’s job is to help kids change their thinking,
or what I call their mind-set, so that when they’re older, they won’t
look back and wish they had tried things but didn’t because their
thinking held them back.
OLIVER: What do you mean?
COUNSELOR: I hear you saying, “Not good at eating equals not being
good at basketball. There’s no need try, because I won’t be good.”
OLIVER: I do say that in my head.
COUNSELOR: Here’s what I think. What if you changed those sentences in your head? You assume you won’t be good at something
because you have problems with your eating, but what are the facts?
OLIVER: What do you mean by “facts?”
COUNSELOR: Let’s look at what is true about you and basketball so
that when you are 78 you don’t look back and say, “I wish when I was
10, I would have challenged my self-talk and at least tried basketball.”
OLIVER: I don’t think I want to regret not trying.
Following my exchange with Oliver, and keeping the tape measure on the floor for reference, I worked with Oliver at a dry erase
board, writing his fixed mind-set sentences and challenging them
with growth mind-set sentences.
The purpose of this chapter is to present information about resilience, a growth
mind-set, grit, and protective factors that provide a solid foundation for helping young
clients cope with challenging life events. Suggestions for counselors working with
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children from a strengths-based orientation will also be discussed. In addition, this
chapter also addresses some of the more serious life events children and adolescents
may experience and how to help them deal with these challenges.
RESILIENCE
Resilience is the ability to bounce back after adversity and to effectively cope with
distressing situations. Resilient individuals have the ability to overcome negative risk
factors and challenges in their lives and still achieve positive outcomes (Stratta et al.,
2015) in various areas of functioning, such as academic achievement, developmental
milestones, competence, well-being, and positive relationships (Shiner & Masten,
2012). Resilient children are able to progress developmentally despite growing up in
disadvantaged environments or experiencing traumatic or challenging circumstances.
Resilience results naturally from normal adaptation processes, which promote positive development despite severe adversity. An impaired ability to adapt or prolonged
exposure to environmental hazards, however, can hinder the natural development
of resilience (Masten, 2001). It is helpful for counselors to view resilience in children
and adolescents as “a process to harness resources in order to sustain well-being”
(Southwick, Bonanno, Masten, Panter-Brick, & Yehuda, 2014, p. 5). Counselors can
help foster resilience by identifying and building on young clients’ strengths, abilities, skills, characteristics, and relationships, which are known as protective factors.
PROTECTIVE FACTORS IN RESILIENT CHILDREN
AND ADOLESCENTS
Children and adolescents who are identified as resilient have demonstrated personal
strengths and protective factors that allow them to overcome adversity and thrive
(Southwick et al., 2014). Protective factors buffer against negative risk factors and
lead to resilient outcomes. Protective factors can decrease risk, reduce the effects
of a negative risk factor, or strengthen the ability to cope (Lee et al., 2013). Some
protective factors can evoke other protective factors, known as a cascade effect. For
example, having a positive relationship with a teacher may lead to a positive attitude
toward school and pro-social relationships with peers (Eriksson, Cater, Andershed,
& Andershed, 2010).
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CHARACTERISTICS
Researchers have identified a number of protective factors that can help children
develop resilience. For example, in a study investigating protective factors in 710
adolescents exposed to war in the Middle East, researchers found that the adolescents who used problem-solving techniques, engaged in leisure activities other than
television, and had supportive parents reported the least amount of psychological
and traumatic stress symptoms (Fayyad et al., 2017). Lee and colleagues (2013)
reviewed 33 research studies and found that protective factors had the largest effect
on the development of resilience. Negative risk factors, such as negative affect or
perceived stress, had a medium effect, and demographic variables had a small effect.
These authors reported that the protective factor of self-efficacy, which is the belief
in one’s own ability to cope and utilize a variety of problem-solving skills, was most
strongly related to resilience, as was positive affect. According to Lee and colleagues,
resilience consists of self-efficacy, self-esteem, and positive affect.
Protective factors can be organized into three categories: individual, family, and
environmental/situational (Eriksson et al., 2010). Individual protective factors include
characteristics, skills, and abilities that children and adolescents possess. These can be
fixed traits, such as temperament, as well as factors that can be learned or developed,
such as coping skills or positive affect. Family-related protective factors include the
quality of family relationships, parental characteristics, the family’s socio-economic
status, culture, and so forth. Environmental/situational protective factors include
things such as the quality of the neighborhood, peer social support, and the school
environment. Counselors should consider all three areas of protective factors when
working with children and adolescents to help them cultivate greater resilience.
The following protective factors that cut across individual, family, and environmental/situational categories can be used to help young clients build resilience.
Grit
Grit describes a characteristic that encompasses passion and perseverance. Sturman
and Zappala-Pieme (2017) define grit as the ability to “sustain a focused effort to achieve
success in a task, regardless of the challenges that present themselves, and the ability to
overcome setbacks” (p. 2). Thus, grit involves stamina, perseverance, and maintenance of
effort over time to reach a desired goal (Duckworth, Peterson, Matthews, & Kelly, 2007).
Proactive Orientation
A defining characteristic of resilience is having an internal locus of control and believing in one’s own effectiveness, which Benavides (2015) labeled proactive orientation.
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Proactive orientation is having a realistic and positive sense of self and a belief that
one can have an impact on a situation or the environment. Proactive orientation
includes hope, a positive outlook, self-esteem, self-efficacy, an internal locus of control, and problem-solving and coping skills, according to Benavides (2015).
Self-Regulation
Self-regulation includes the ability to demonstrate self-control, as well as the ability to
modulate both positive and negative emotions. Self-regulation is a fundamental protective
factor that appears to form the basis for positive interpersonal relationships, compliant
behavior, and reduced depression and anxiety. Self-regulation includes impulse control,
the ability to delay gratification, the ability to self-soothe, and the ability to regulate
attention and emotions (Benavides, 2015; Korucu, Selcuk, & Harma, 2016).
Proactive Parenting
Children need to have at last one warm, loving, nurturing caregiver in their lives who
provides appropriate limits and boundaries (Benavides, 2015). Authoritative parenting,
a parenting style that provides nurturance as well as consistent, but not overbearing
control, has been shown to foster resilience in children. As you read in chapter 7, an
authoritative parenting approach includes good communication, appropriate limit
setting, responsive attention, and a supportive atmosphere (Korucu et al., 2016).
Connections and Attachments
A feeling of belonging is a fundamental human need. It is important that children
have supportive relationships with family and other adults. They also need to know
how to develop friendships and maintain peer relationships (Benavides, 2015).
School Achievement, Involvement, Special Talents
Academic achievement and active engagement in school help children develop
resilience. Engaging in extracurricular activities can serve as a protective factor
(Armstrong & Manion, 2013), as can having a positive attitude about school and
high academic achievement (Jolliffe, Farrington, Loeber, & Pardini, 2016).
Community
Children can develop resilience through relationships with positive role models outside
the family. Joining prosocial groups such as clubs, teams, and religious or spiritual
organizations provide safe and structured environments for exploring and developing
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interests and skills (Eriksson et al., 2010). Counselors can advocate for safer neighborhoods, good recreational facilities, and support services in the community.
CULTURAL CONSIDERATIONS
It is important to remember that what is considered a protective factor in one culture
may not be a protective factor in another culture. For example, African infants with
an easy temperament, considered to be a protective factor in the United States, had
a lower survival rate during a drought than their Western culture peers who had
difficult temperaments (e.g., high reactivity and low sociability) (Eriksson et al.,
2010). Counselors need to understand the children’s context, family, and culture
when providing interventions that promote protective factors.
For instance, African American children and adolescents, as well as other minority
groups, regularly experience the stress of discrimination. Yet, the majority of them
demonstrate positive outcomes despite this adversity, suggesting that minority
children possess protective factors that buffer against the harmful effects of discrimination (Gaylord-Harden, Burrow, & Cunningham, 2012). Researchers have identified
ethnic identity, racial socialization, and culturally relevant coping as protective factors
for African American and other minority youth. Ethnic identity provides a sense of
belonging to an ethnic group, racial socialization involves transmitting knowledge
to children about values and racial issues, and culturally relevant coping consists of
strategies grounded in the history and traditions of a specific culture. Counselors
should build upon culturally specific protective factors when appropriate. Read the
“Now Try This!” sidebar and consider following its directive as a way to connect
with a child who has a protective factor such as culturally relevant coping.
NOW TRY THIS!
One way to understand the presence of trusted adults in a young person’s
culture is to conduct the activity “Your Starting Five.” Connect with two
children in your neighborhood. Ask them to think about a basketball team
and draw or list the “starting five” adults in their community that they would
want in the game with them. Discuss with them why they chose these particular adults to be on their team and if they feel good about their team. Ask
them if these adults could help them cope if they are experiencing difficult
times and whether they need additional team members who better understand their culture and background. This is a valuable exercise to access for
the protective factor of connectedness.
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INTERVENTIONS FOR PROTECTIVE FACTORS
When children show an interest in a particular goal, counselors can cultivate grit by
providing support and connecting young clients with resources. It is important to
help them develop stamina by preparing them to anticipate failures and setbacks as
they work toward a goal (Duckworth et al., 2007). Counselors can provide encouragement to persevere after setbacks, teach children to focus on effort over results,
emphasize progress over perfection, and model appropriate positive self-talk. Grit is
also associated with a growth mind-set, which will be discussed later in the chapter.
A number of cognitive behavioral interventions can be used to cultivate protective
factors. Counselors can teach problem-solving skills to help young clients differentiate
between controllable and uncontrollable circumstances, as well as relaxation and
self-control strategies. They can also employ cognitive restructuring and reframing
to teach clients to think differently and can help children and adolescents develop
optimistic thinking. One technique called “Doors” teaches optimism by having
children visualize one door closing and a better one opening. A process question
is, “Has there been a time when something seemed really bad or almost impossible,
but then something good happened instead?” (Davis, 2014, para. 12). Appropriate
self-disclosure can help guide them through this activity, which helps young clients
learn that “positive things may come from seemingly hopeless situations” (Davis,
2014, para. 12). It is also helpful to teach them about perspective taking. An excellent
book to facilitate this is the True Story of the Three Little Pigs (Scieszka, 2014), which
is told from the wolf’s perspective.
Counselors can also teach young clients how to identify both positive and negative feelings in various situations, which helps them gain a sense of control over
their emotions. In addition, counselors can help children identify their strengths
and positive experiences. An intervention that helps them cultivate positive affect is
asking them to identify three good things that have happened to them. Once they
identify these good things, ask how these things happened, how they reacted, and
how others responded to their reaction. This helps to reinforce positive emotions
and to develop a positive mind-set (Davis, 2014, para. 5–6). Games such as “Bounce
Back: A Game that Teaches Resiliency Skills” (teen or children’s version, available
from Childswork/Childsplay) can also build resilience.
There are a number of ways protective factors can be cultivated in children and
adolescents, their families, or their communities. Counselors can play a critical role
in offsetting the impact of the risks and vulnerabilities children and adolescents
experience by providing a safe space for them to explore and process their emotions
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and teaching skills that help them “achieve their best despite life’s hurdles and hardships” (Davis, 2014, para. 16).
GROWTH MIND-SET VS. FIXED MIND-SET
At some point in your training, many of you have been exposed to Albert Ellis’s
theory of rational emotive behavior therapy (REBT) (Vernon, 2016). Ellis’s explanation for why humans behave the way they do is that the way they think affects
the way they feel and, thus, the way they behave. In other words, it is not an event,
person, or situation that makes them feel or behave a certain way; it’s their thinking.
Closely tied to Ellis’s theory is positive psychology, developed by Martin Seligman.
Positive psychology refers to a process of working with clients to increase happiness
and life satisfaction using interventions that emphasize focusing on positive events
in daily life, expressing gratitude, and using personal strengths such as curiosity
and persistence (Owens & Patterson, 2013). In working with children and adolescents, we think you will benefit by understanding how their positive and negative
attitudes and beliefs (assumptions, irrational beliefs, and facts), help them develop
a meaning-making framework.
Combining the concepts of negative self-talk (REBT) and positive self-talk (positive
psychology) is what writers identify as a fixed vs. a growth mind-set (Dweck, 2016).
A fixed mind-set refers to a mental position that is unchanging and fosters negative
thinking. In a fixed mind-set, intelligence in viewed as unchanging. For example, a
child or adolescent with a fixed mind-set might say, “I will never be able to do this”; “I
can’t change”; “This will never get better.” To children with a fixed mind-set, failure is
often seen as confirmation that they don’t possess a certain skill or strength. Children
who possess a fixed mind-set often present with the following characteristics: (a) they
view events or outcomes as a direct measure of their competence and worth; (b) they
feel paralyzed and helpless to change or improve their life events; (c) they possess an
external locus of control; (d) they see criticism as debilitating; and (e) they require
constant “proving” of intelligence or ability, which interferes with their ability to try
new things because a failure would prove inadequacy (Dweck, 2016).
In contrast, a growth mind-set is defined by the belief that intelligence can change,
grow, and develop. Children who possess a growth mind-set view their intelligence as
something that can develop and change using learning strategies, hard work, and effort
(Dweck, 2016). Children and adolescents who possess a growth mind-set understand
that the brain can grow like a plant, that they can learn from mistakes, and that mistakes
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are good! Young clients with a growth mind-set say things such as, “I won’t give up”; I
will keep trying”; “I can do this.” Furthermore, children who possess a growth mindset have the following characteristics: (a) they view failure as a learning opportunity;
(b) they view all human qualities as something that can be developed or fostered through
awareness, hard work, perseverance, determination, struggle, learning, and practice;
(c) they understand that life can be improved with focused practice, reflection, strategizing, and development of new skills that allow success to follow; (d) they possess an
internal locus of control; (e) they view criticism as an asset (Dweck, 2016).
A growth mind-set allows for a more accurate and rational evaluation of personal
assets and deficits because deficits are not seen as failures. Counselors who work with
children from a growth mind-set help them understand that outcomes are not necessarily indicators of ability or intelligence; they are learning opportunities (Dweck, 2016).
Research has shown that despite their intellectual abilities or which end of the
spectrum they are on (growth mind-set or fixed mind-set), it is what children believe
about how they learn and the challenges they face that determines their ability to be
successful (Blackwell, Trzesniewski, & Dweck, 2007). Thus, children who subscribe
to or are taught one “meaning system” (Blackwell, et al., 2007, p. 247), such as a
growth mind-set over a fixed mind-set, will be better able to overcome challenges at
critical junctions in their lives. Claro, Paunesku, and Dweck (2016) found that high
school-aged students in the lowest 10th percentile of family income who exhibited a
growth mind-set performed academically as well as their peers who exhibited a fixed
mind-set but were in the 80th income percentile, thereby mitigating the potential
of low socioeconomic status on achievement. Read about Anna’s experience with
growth mind-set groups in the “Voices From the Field” sidebar.
VOICES FROM THE FIELD—PROFESSIONAL VOICE
I hosted two counseling interns this year and together we ran seven growth mindset groups in the span of 4 months. Before the groups began, I had a back log
of counseling referrals for students who were generally unmotivated, struggled
in their classes, and often acted out in their classrooms. Now, 4 months later, the
referrals have dropped by more than 50%; I no longer have a back log of teacher
referrals. The children in these groups are excited to come to group and excited
to learn new ways to approach their challenges in and out of the classroom.
—Anna, elementary school counselor
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Intentionally teaching a growth mind-set using creative techniques can help
young clients deal with life’s challenges. Learn a creative technique to teach growth
mind-set in the “Add This to Your Toolbox” sidebar.
ADD THIS TO YOUR TOOLBOX
After a client has read a book with a growth mind-set theme, such as Salt
in His Shoes by Michael Jordan or The Girl Who Never Made Mistakes by
Mark Pett and Gary Rubinstein, tape a line on the floor and label one side of
the room “fixed mind-set” and the other side “growth mind-set.” Give your
client 10 separate index cards with sentences illustrating a fixed or growth
mind-set. Give your client the cards and ask him or her to place cards on
the appropriate side of the tape. Help him or her reword fixed mind-set
sentences to growth mind-set sentences.
What stronger support is there for teaching a concept than to hear its impact on
an actual client? Read the “Voices From the Field” sidebar to get a child’s perspective
on growth mind-set.
VOICES FROM THE FIELD—A YOUNG CLIENT
It (growth mind-set) helped me to learn that giving up isn’t the answer. If you
don’t get it the first time, try again and again. It helped me to think positive and
to ask for help/advice when I need it.
—Lily, fifth grader after participating in
a growth mind-set small group
In this next section, we will describe some of the challenging life circumstances that
children and adolescents often face. As it is beyond the scope of this chapter to cover
all challenges, we have highlighted several that we consider to be most important.
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COUNSELING CHILDREN AND ADOLESCENTS FROM
VARIOUS TYPES OF FAMILY STRUCTURES
Children and adolescents who grow up in traditional two-parent families are certainly not exempt from difficulties and challenges. Gone are the days where the word
“family” refers to the 1960s concept of the traditional nuclear family consisting of
two married, biological parents with only full biological siblings present in the home.
Today’s families come in many different configurations, but regardless, proactive
parenting and strong family support can serve as a protective factor for children
and adolescents. Although one warm, caring parent can provide for a child’s needs,
it is important to note the changing family structure and its impact on children.
Family dynamics play a significant role when children exhibit problem behaviors,
and children and adolescents in families with changing structures are more prone
to at-risk behaviors (Capuzzi & Gross, 2014).
In the nearly 60 years between 1960 and 2017, children who live with both parents declined from just over 80% to right under 70%. Nearly 20 million children,
or 27.1%, under the age of 18 live with just one parent. Historically, children in
single-parent homes were raised by mothers, but there has been an increase from
12.5% in 2007 to 16.1% in 2017 for children living with only a father. Additionally,
many children live with grandparents instead of with a parent. In 2009, more than
half of the children living with neither parent were living with grandparents (United
States Census Bureau, 2017a).
While families experience shifts in structure due to various reasons, the most
common reason that family structures shift is divorce or the termination of a parental
partnership. In addition to adjusting to living in a single-parent household, children
can also experience difficulties with stepfamily issues when one or both parents
remarry. Children and adolescents living with adopted families and in families
with same-gender parents also face challenges, as described in the following section.
COUNSELING CHILDREN AND ADOLESCENTS OF DIVORCE
Since the late 1990s, many states discontinued reporting official numbers on marriages
ending in divorce; therefore, reporting accurate statistics on divorce is challenging.
What we do know is that in 2010, 30.8% of men reported they were married compared to 54.8% in 1940. In 2010, 39.2% of women reported being married compared
to 68% in 1940 (United States Census Bureau, 2010). According to the American
Academy of Child and Adolescent Psychiatry (2017), one out of every two marriages
ends in divorce, and many of those families include children.
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Characteristics
Parents would like to believe that divorce has a minimal effect on their children,
but experts agree that children in the midst of a parental divorce often experience
guilt, abandonment, and loyalty conflicts (Basson, 2013). Additionally, most children
will feel fearful, sad, and angry in varying degrees. They may also experience grief,
loneliness, and rejection. (McFarland & Tollerud, 2009).
Counselors who work with young clients during times of divorce or partnership break-up will want to address the following issues in individual and/or small
group counseling:
1.
Divorce-related misconceptions. Oftentimes young clients think they are the
only children on the planet whose parents are splitting up, that the divorce
was their fault, or that there is a good possibility that their parents will reunite.
Adolescents in particular may think they shouldn’t invest in a relationship
because, like their parents, it will probably fail.
2.
The new reality. Many parents find it difficult to talk about the separation or
divorce openly, and, as a result, children may have difficulty acknowledging
the reality of it.
3.
Loyalty conflicts. Children often need permission to love each parent equally.
This needs to be pointed out to parents, stressing that it is best for children to
have positive relationships with both parents.
4.
Expression of feelings. Children may lack the verbal skills to express the sadness,
anger, guilt, anxiety, confusion, or grief they are experiencing.
5.
Feelings of abandonment. Children may feel abandoned, especially when one
parent becomes less involved as a result of the break-up. Counselors will want
to address the child’s assumptions that they are unlovable or that the parent
left because he or she didn’t love the child.
6.
Parental conflict. Children may be drawn into parental conflict, which can
even result in safety issues. They need to know how to protect themselves and
understand that they are not the cause of the conflict.
Most families adjust to the change in family structure within 2 to 3 years following a break-up. However, how well and how quickly children adjust depends
on a number of factors, including whether there is less family income or if they
have to move and adjust to a new home or school (Margolis, Dacey, & Kenny,
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2006; McFarland & Tollerud, 2009). An additional factor that affects a child’s
adjustment includes temperament and personality. For children who do not adjust
to change easily, a divorce and a family restructuring can prove more damaging than to those who are less affected by change. Finally, age can impact how
quickly they adjust. Adolescents tend to better understand why parents divorce
and can more easily express their feelings. According to Margolis and colleagues
(2006), they also tend to have a broader support system of peers, who serve as a
protective factor.
Interventions
Research shows support for the use of small group counseling in the treatment of the
psychological, social, and academic problems children of divorce experience (Cercone
& DeLucia-Waack, 2012; DeLucia-Waack, 2006). Children of divorce typically need
to focus on resolving common psychological tasks. Either individually or in groups,
counselors should help young clients with the following:
1.
Use art, play, music, and other creative interventions to help them express
how they currently view their family situation: Are they in denial about the
divorce/separation or are they entertaining fantasies about reunification? For
example, ask young clients to rate the possibility of reunification on a scale
from 1–10, and then ask them to rate how they think their parents would rate
that possibility. Or, have them draw a picture of the worst things that could
possibly happen if their parents don’t get back together.
2.
Help them resolve anger and self-blame by using evidenced-based counseling theories such as REBT (chapter 7) and solution-focused brief therapy
(chapter 5) to help young clients dispute or reframe their cognitive distortions. Bibliotherapy can also be a powerful tool to help children challenge
self-talk, such as Dinosaurs Divorce (Brown, 2009), or The D Word: Divorce
(Cook, 2011).
3.
Help them deal with the grief and loss: the loss associated with not living
with both parents, loss of a certain lifestyle if there is a decrease in family
income, or the loss associated with an oftentimes necessitated move to a new
home or school. Small group counseling is an extremely effective treatment
for processing loss. Pugliese (2018) provides a good small group counseling
sequence for all grade levels.
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4.
Strengthen effective coping skills. Teaching children to recognize when they
are anxious or experiencing stress will enable them to use techniques such as
tapping, relaxation techniques, or mindfulness to mitigate the anxiety.
5.
Reduce the stress of living or moving between two homes. Brainstorm with
young clients about how to make the transition less stressful, such as keeping a
calendar so they know where they will be each day, or keeping clothes, games,
toiletries, and other familiar things in both homes.
6.
Teach young clients how to use rational coping self-statements to help them
cope with troubling aspects of the divorce/separation: “Even though this is
really hard, I still get to see both my parents.”
7.
Have them interview other kids who have adjusted to their parent’s divorce
to help them see that they, too, can get through this. Bibliotherapy is also an
excellent way to help get this point across.
It is also imperative to help parents understand that when they shame or degrade
the other biological parent, they, in essence, shame the child; the child is a part of
both parents. Counselors should stress to both parents the importance of developing
a cooperative relationship to facilitate working out living arrangements and routines,
which in turn will make the adjustment for young clients less stressful.
COUNSELING CHILDREN AND ADOLESCENTS
IN BLENDED FAMILIES
Research has, in the past, shown that children and adolescents raised in non-intact
families do not fare as well in life as do those from families with two biological
parents. The percentage of children living in homes without either of their parents
is approaching 5% of the total childhood population in the United States (U.S.
Census, 2017b). Research historically has found that high school graduation rates,
college enrollment, and college graduation rates for children from single-parent and
stepparent families are below those of children from two-parent families (Bjorklund,
Ginther, & Sundstrom, 2005). According to the 2010 U.S. Census, over 6% of all
children under the age of 18 were living in homes without two biological parents
in the same household. This group included both stepchildren (4.3%) and adopted
children (2.4%) (Kreider & Lofquist, 2014).
According to Kreider & Lofquist (2014), the traditional definition of a stepchild
was “the biological child of an individual’s spouse who was not also the individual’s
biological child” (p. 3). However, in recent years, “stepchild” may also be used to
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refer to children being raised by two individuals who are not or may have never
been married. Additionally, it has become increasingly difficult to parse out data
and statistics on children who have been adopted. In recent surveys of families and
the members living under one roof, it has become apparent that adults no longer
clearly distinguish between non-biological children who live with them via a new
marriage, an international adoption, or through the foster care system or private
domestic adoptions. For this reason, in this section, we also include children who
have been adopted in the discussion about blended families.
Statistics from the American Academy of Child and Adolescent Psychiatry (2017)
indicate that approximately 120,000 children are adopted each year in the United
States. Therefore, given the high numbers of children living in households where
the familial arrangement is, at times, complicated, counselors are sure to encounter
individuals who have been adopted, are living with only one or no biological parent,
or are living with a grandparent or a foster parent.
Characteristics
According to Visher and Visher (2014), there are certain characteristics that specifically exist in stepfamilies. These include a family that originates from loss or
change; incongruent individual, marital, and family life cycles; children and adults
with expectations from previous families; parent-child dynamics that pre-date the
new living arrangement; a biological parent residing elsewhere or in memory; children who are often members of two households; and non-existent or ambiguous
custodial rights of stepparents.
Given that these unique characteristics exist, counselors will want to focus their
efforts on assisting children and adolescents in dealing with loss and change, similar to the issues faced by young clients experiencing divorce. Additionally, they
should focus on the specific developmental needs of children and adolescents as
they transition to a new family (young children typically adjust more easily than
adolescents, and adjustment for teenagers is typically harder when the “new parent”
is the opposite sex) (McFarland & Tollerud, 2009).
Counselors can also help children and adolescents develop and accept new family
traditions. At first, children may be resistant or feel guilty about engaging in and
enjoying activities in the new family. Also, counselors must help young clients
understand and adjust to continual shifts in household composition (Visher & Visher,
2014). Children and adolescents who do not have opportunities to work through the
stress often involved in the changing family landscape can exhibit signs of anger,
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low self-esteem, and guilt. They may act out in school, have difficulty concentrating, or experience physical effects of stress, including headaches and stomachaches
(McFarland & Tollerud, 2009).
Interventions
Counselors can help young clients who are struggling with a changing family structure address issues of loss, loyalty, and lack of control (Visher & Visher, 2014). Adopted
children and adolescents should have the opportunity to receive as much information
about their backgrounds as is age appropriate, depending on their ability to process
and cope with the information.
As stated throughout this text, counselors should make counseling engaging for
children and adolescents. Several creative interventions/resources to help young
clients cope and adjust to their changing family follow:
1.
Cory Helps Kids Cope with Divorce: Playful Therapeutic Activities for Young
Children (for young children) (Lowenstein, 2013). This is the first in a series
of books that helps children address feelings associated with divorce and a
changing family. The book includes numerous therapeutic games, art, and
play activities.
2.
Kinetic family sculpture. Young clients (and even family members) work
together using art supplies to process loss or family sub-systems such as sibling relationships. Clients use art materials to create a visual representation of
the family and counselors help them process the sculpture, allowing them to
move members around as processing takes place (Brandon & Goldberg, 2017).
3.
Sibling group play therapy. Child-centered play therapy involving siblings is
an effective way to establish a safe, understanding environment where new
siblings can begin to understand how they interact with others and learn new
ways of interacting (Purswell & Taylor, 2013).
4.
Puppetry. Using puppets allows young clients to express conflicts through
metaphors. This technique allows the counselor to identify themes and observe
progress in communication patterns and decision-making strategies (Purswell
& Taylor, 2013).
5.
Sandtray group counseling. Sandtray and group counseling have each been
proven effective in counseling adolescents. When combined, sandtray group
counseling allows adolescents to connect with peers who are experiencing
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new family configurations while also allowing members to address interpersonal concerns, improve socialization, and develop a caring community.
Members work with individual trays of sand, build small worlds representing
their experiences, and share their creations with the group (Draper, Ritter, &
Willingham, 2003).
COUNSELING CHILDREN AND ADOLESCENTS
WITH LGBTQ PARENTS
There is scant research confirming the idea that children and adolescents who grow
up in homes where parents are the same gender suffer psychological stressors more
frequently than their peers who do not live with same-gender parents. According to
Power and von Doussa (2014), international studies have shown that children who
have same-gender attracted parents “do just as well as any other children emotionally, socially, and educationally” (p. 23).
Characteristics
Bos and van Balen (2008) found that even the most common issue that these children face, stigmatization by peers, was reportedly low for the 8- to 12-year-olds
in their study. Boys in the study reported that they felt like they were excluded
by their peers because of their family structure. Girls more often reported that
their peers gossiped about their family structure. As a result, the stigmatization
experienced by these children produced higher levels of hyperactivity in boys
and lower self-esteem in girls. However, it should be noted that children can be
teased or bullied for a whole host of reasons. Having same-gender parents “does
not necessarily expose children to teasing and bullying more than other issues”
(Power & von Doussa, 2014, p. 23).
Interventions
Counselors who work with children of same-gender parents must be aware of the
protective factors that can help these children buffer against the potential negative
effects of stigmatization and teasing. One of the strongest protective factors is to
provide opportunities for children and adolescents to know others from LGBTQ
families. Counselors should consider small group counseling where young clients
have the opportunity to interact with peers who are experiencing similar problems
with stigmatization or harassment and share ways that they are dealing with living
in a same-gender parent household (Power & von Doussa, 2014).
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Additionally, practical resources to assist mental health professionals, as well as
teachers, can be found on GLSEN’s website. Ready, Set, Respect: GLSEN’s Elementary
School Toolkit (GLSEN, 2016a) provides LGBTQ-inclusive family diversity-focused
lessons that can be used as standalone lessons or part of school-wide efforts to reduce
bias and bullying. Specific lessons on family diversity include titles such as “What
Makes a Family?” (p. 26) and “Respect for My Family … and Yours” (p. 35). One
particular lesson in GLSEN’s program, “The Ins and Outs of Groups” (p. 17), explores
feelings of being in majority and minority groups, as well as feelings associated with
being excluded and teased. This is just one example that holds particular promise
for working with children in LGBTQ families in small groups.
Counselors should be advocates for simple practices that can help young clients
with same-gender parents feel more included and affirmed. For example, schools
and agencies can provide information and intake forms that are more inclusive of
LGBTQ families by asking for information from “parent 1” and “parent 2” versus
“mom” and “dad.” GLSEN’s “Safe Space Kit” provides ideas about how to assess
climate, policies, and practices in schools or agencies and strategies to increase
advocacy efforts (GLSEN, 2016b).
CHALLENGES FACED BY CHILDREN AND ADOLESCENTS
WITH EATING AND FEEDING DISORDERS
The DSM-V (APA, 2013) recognizes six primary feeding and eating disorders,
including anorexia nervosa (AN), bulimia nervosa (BN) binge-eating disorder,
pica, rumination disorder, and avoidant/restrictive food intake disorder (ARFID)
(APA, 2013). In this section, we focus on anorexia and bulimia. We also comment
on feeding disorders because Oliver, in our opening vignette, was struggling with
a feeding disorder (a food aversion).
CHARACTERISTICS
According to Bould, Newbegin, Stewart, Stein, and Fazel (2017), “[E]ating disorders
are a group of conditions in which negative beliefs about eating, body shape, and
weight accompany behaviors including restricting eating, binge eating, excessive
exercise, vomiting, and laxative use” (p. 359). According to the National Eating
Disorders Association (NEDA, 2018), approximately 30 million people in the U.S.
will struggle with a clinically significant eating disorder at some point in their
lives. The mortality rate associated with anorexia nervosa (AN) is 12 times higher
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than the death rate associated with any other causes of death for females age 15–24
(Anderson & Nicolay, 2016). And while the majority of young people affected by
eating disorders are adolescent girls, adolescent boys are not immune.
According to the NAED (2018), the reasons behind the development of eating
disorders can be complex and can be caused by a combination of biological, psychological, and social factors. Biologically, having a family member (parent or sibling)
with an eating disorder puts youth at an increased risk. Mental health conditions
such as depression, anxiety, and addiction also run in families and can increase
risk for an eating disorder. Psychologically, perfectionism is one of the strongest
risk factors for the development of an eating disorder. A personal history of anxiety
disorder and body image dissatisfaction can also contribute to risk. Socially, risk
factors include an overexposure to images that young clients often see on television
and social media that convey that “thinner is better” or a weight stigma. These risk
factors, coupled with exposure to bullying and teasing about a person’s weight, can
significantly increase the risk of developing an eating disorder (NAED, 2018).
We cannot possibly provide a comprehensive review of all eating disorders in a
single chapter, but a basic knowledge of anorexia (AN) and bulimia (BN) is necessary in your work with children and adolescents. In addition to these common
disorders, counselors also need to be aware of an emergence of feeding disorders,
such as problem feeders, selective eating disorders, and food aversion, which often
manifest themselves in young children. The broader concept of feeding disorders
describes issues with “gathering food in the mouth and sucking, chewing, or swallowing for appropriate intake” (Rowell & McGlothlin, 2015, p. 3). Problem feeders
describe children who eat less than 20 foods, drop foods without adding new foods,
eat different foods than the rest of the family, avoid entire food groups, and become
upset when new foods are offered. Children with selective eating disorders have a
limited range of accepted foods and refuse to try unfamiliar foods. Food aversion
typically occurs in children following some uncomfortable experience with food
such as illness, trauma, or choking and often occurs in combination with problem
feeding or selective eating (Rowell & McGlothlin, 2015).
Eating disorder experts often use the terms “typical eating” or “disordered eating” to
discuss feeding issues. There is wide continuum on which to categorize typical eaters that
varies across individuals, families, and cultures. To fully evaluate if a child is a typical
eater, one must consider patterns of eating, as well as typical growth and development
across the lifespan. The concept of disordered eating can be broadly defined as any
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pattern of eating that is harmful to a child’s emotional, physical, or social health and
development and is a problem for the child or the family (Rowell & McGlothlin, 2015).
Signs and symptoms of disordered eating may include the following for AN:
chronic dieting and dramatic weight loss, an inability to maintain an age-appropriate
body weight, dressing in layers to hide weight or to stay warm, and maintaining an
excessive and rigid exercise regime. Signs and symptoms of BN include evidence
of purging, frequent trips to the restroom following meals, evidence of laxative or
diuretic use, and dental problems associated with frequent vomiting, including
enamel erosion and cavities (Meyers, 2018; NAED, 2018).
It is important for counselors to know that clients with eating-related problems
likely present in counseling with other issues, such as depression, anxiety, and
relational problems, all of which need to be addressed in the course of successful
treatment of an eating disorder (Meyers, 2018). Eating disorder clients are often
resistant to treatment, so this work can be challenging.
INTERVENTIONS
According to Hamilton (2007), treatment for eating disorders in preadolescents
needs to include counseling interventions that align with growth mind-set concepts, including resiliency and self-esteem. Traditional approaches such as cognitive
behavioral therapy, coupled with experiential therapies, such as play and art therapy,
may provide the best opportunity for recovery. Additional counseling interventions
might include the following:
1.
Body hatred disputation. Challenging distorted thoughts such as “I’m ugly
and unlovable in this body” is an essential piece of most recovery programs
(Meyers, 2018, p. 26)
2.
Intuitive eating (IE) education. IE refers to an educational program in which
clients learn that foods are neither “good” nor “bad” and that eating is based
on listening to the cues that their body provides (Meyers, 2018)
3.
Mindfulness education. These strategies provide a way to recognize the onset
of an urge to binge or purge (Meyers, 2018).
4.
Small group counseling interventions. The Body Project (2018) is an early
intervention program for high school-aged females that teaches skills to confront unrealistic beauty ideals, develop a healthy body image, and promote
self-esteem (NDEA, 2018).
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5.
Journaling, writing, and drawing. Creative interventions provide a way to distract the mind from a desire to binge, purge, or restrict eating (Meyers, 2018).
6.
The Be Body Positive Model (2018). This program provides a body-oriented,
social emotional educational program for young clients from all backgrounds.
The program focuses on boosting positive body image while improving clients’
physical, emotional, and psychological health.
7.
Anxiety, stress, and power struggles. Especially for children with feeding disorders, counselors must work with families to reduce stressful mealtimes and
set realistic expectations for eating (Rowell & McGlothlin, 2015).
Counselors who work with youth struggling with eating/feeding disorders must
collaborate closely with trained physicians and nutritionists who can provide appropriate medications, if needed; monitor proper diets and caloric intake needed for
appropriate development; and provide advice on whether hospitalization is required
(Meyers, 2018). Finally, information and best practices in the eating disorder field
are ever-changing. Read the “Personal Reflection” sidebar for Chris’s professional
perspective on being open to continued learning in this area.
PERSONAL REFLECTION
When I first met Oliver, the client in the opening of the chapter, I was familiar
with disordered eating such as anorexia and bulimia, but not eating issues
commonly labeled as more atypical eating. Early on I discovered that my
go-to interventions (REBT) were unsuccessful and that was new territory for
me. I had to become a student and educate myself on sensory food aversion, extreme picky eating, and atypical eating. My advice is to remain open
to learning about challenges that children face; not everything gets covered
in your training program. Be willing to admit that you don’t know exactly
what is going on with a child or how to approach it, but stay willing to learn.
—Chris Schimmel
CHALLENGES FACED BY LGBTQIA+ CHILDREN AND
ADOLESCENTS
The acronym LGBTQIA+ is used to describe the group of individuals considered to
be sexual and gender minorities; in other words, individuals whose orientation or
gender is anything other than cisgender heterosexual (those “whose gender identity
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aligns with the one typically associated with the sex assigned to them at birth,”
PFLAG, 2018, para. 13). The LGBTQIA+ acronym is used by those who choose
“sexual or gender identity labels as personally meaningful for them” (Russell &
Fish, 2106, p. 2). For the purposes of this chapter, the acronym indicates youth
who identify as lesbian, gay, bisexual, transgender, queer or questioning, intersex,
and ally or asexual. The “+” at the end of the acronym indicates there are more
identities and terms to acknowledge, including the understanding that gender is
not either/or; many people identify as non-binary or gender fluid. People may also
identify their sex (i.e., anatomical or physiological attributes) as non-binary, as some
children are born with ambiguous genitalia (i.e., intersex or differences of sexual
development, PFLAG, 2018). Gender and sexual orientation are on a continuum,
and people can fall at either end or in between. Because gender and sexuality are
so complex, the first step in understanding LGBTQIA+ youth is to keep up to date
with the language, acronyms, and pronouns, with the caveat that labels are not
meant to be prescriptive; they are a means to best understand if or when a client
self-identifies. As a detailed explanation of sexual and gender identity is beyond
the scope of this chapter, you are encouraged to do more research to prepare you
to work with this population.
CHARACTERISTICS
It is critical that counselors understand the challenges LGBTQIA+ youth face,
as well as how to provide safety, support, counseling, and advocacy. Youth who
identify as LGBTQIA+ regularly face discrimination and hostility and experience
stressors that are above and beyond typical everyday stressors due to the continued
and pervasive oppression in our society (American Counseling Association; ACA,
2009). These stressors are compounded for LGBTQIA+ youth of color who may
experience a conflict between their sexual orientation/gender identity and their
racial/ethnic identity or cultural community (Singh, Moss, Mingo, & Eaker, n.d.).
Because of chronic victimization, discrimination, and stigmatization, LGBTQIA+
youth are at risk for developing mental health issues or deficits in wellbeing (Russell & Fish, 2016).
In fact, a much greater number of LGBTQIA+ youth feel sad or hopeless compared to heterosexual students, they have higher rates of tobacco and alcohol usage,
and they are five times more likely than heterosexual students to use illegal drugs
(Centers for Disease Control (CDC) (2016). They are at greater risk for depressive
disorders, anxiety disorders, and posttraumatic stress disorder (Russell & Fish, 2016).
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Moreover, the suicide risk statistics are alarmingly high for LGBTQIA+ youth. In a
study of over 15,000 ninth- through 12th-grade students, lesbian and gay students
reported suicide ideation twice as much as their heterosexual peers, and almost four
times as many attempted suicide. The statistics for students who identify as bisexual,
questioning, and transgender are equally alarming (Caputi, Smith, & Ayers, 2017).
For LGBTQIA+ youth, school can be an unsafe place. The CDC (2016) found that
more than twice as many LGBTQIA+ students miss school due to safety concerns
and report higher rates of cyberbullying and bullying at school than do heterosexual
students. LGBTQIA+ students generally cited a hostile school climate as a reason for
dropping out of school. The consequences of school safety concerns for these students
include lower grade point averages, decreased likeliness to pursue higher education,
a sense of not belonging in their school community, lower levels of self-esteem, and
higher levels of depression (Kosciw, Greytak, Giga, Villenas, & Danischewski, 2016).
It is important to note that identifying as LGBTQIA+ is not a risk factor itself;
the risks arise from stressors such as discrimination, harassment, and victimization
that these children and adolescents routinely experience. For example, LGBTQIA+
students are at a greater risk for becoming victims of dating violence, sexual assault,
and physical assault than cisgender heterosexual students (CDC, 2016). However,
they are not innately prone to these negative outcomes; research shows that much
of the problem is attributable to societal and systemic discrimination. Therefore,
even though these youth continue to be at risk for negative mental health outcomes,
many of these outcomes are preventable.
INTERVENTIONS
The American Counseling Association (ACA, 2009) approved the ALGBTIC Competencies for Counseling LBGQIQA and the ALGBTIC Competencies for Counseling
Transgender Clients in 2009 (Association for Lesbian, Gay, Bisexual, and Transgender
Issues in Counseling [ALGBTIC]). These competencies are grounded in a “Strengthbased, Feminist, Multicultural, Social Justice perspective” (ACA, 2009, p. 2), which
should guide counselors’ work with LGBTQIA+ clients. Counselors should identify
and build on clients’ individual and cultural strengths while also considering the
societal and institutional disparities LGBTQIA+ clients face. Counselors must advocate for the alleviation of discrimination and inequities faced by these individuals
and help them to self-advocate. It is also critical for counselors to be aware of personal biases and work to overcome them. As allies and advocates, counselors play
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a critical role in promoting the health and safety of LGBTQIA+ youth in families,
schools, and communities. In doing so, counselors engage in the following activities:
1.
Providing safe spaces. Counselors can designate areas, such as their office,
as safe spaces. The counseling environment should be supportive, caring,
and foster “self-acceptance and personal, social, emotional, and relational
development” (ACA, 2009, p. 1). This encompasses the use of inclusive and
affirming language, accepting clients’ selected gender or sexual identity, and
honoring clients’ preferred labels and terms. LGBTQIA+ youth demonstrate
better emotional health and educational outcomes when they can share their
feelings about sexual orientation and gender identity.
2.
Supporting identity expression. As LGBTQIA+ youth begin to become aware
of their sexual or gender identity, they may experience shame, minimize how
their gender/sexuality affects them, or deny their LGBTQIA+ identity. They
may also experience identity confusion and inner turmoil when they experience attractions or gender expressions that conflict with heteronormative
expectations. Fear of social condemnation may motivate them to keep their
sexual orientation or gender identity secret, which can result in guilt and fear
that affects their relationships, academic progress, and emotional well-being
(Frank & Cannon, 2009). Counselors help LGBTQIA+ youth process, make
sense of, and come to terms with variations in developmental processes through
individual and group counseling.
3.
Respecting the coming out process. The experiences of self-labeling and
self-disclosing vary for each individual. Openly expressing sexual or gender
minority status has been shown to promote positive psychosocial adjustment,
but at the same time, it threatens safety and increases potential victimization.
Therefore, the coming out process is an extremely complex, personal, and an
individualized process influenced by developmental issues and levels of support.
Counselors respect each client’s process with the goal of empowering clients
and fostering self-acceptance and self-efficacy (ACA, 2009; PFLAG, 2018).
4.
Advocating for improved school climate. Much of the work with LGBTQIA+
children and adolescents needs to occur in the schools. The American School
Counselor Association’s (ASCA, 2016) official position states that “[s]chool
counselors promote equal opportunity and respect for all individuals regardless of sexual orientation, gender identity or gender expression” (p. 37). They
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also “work to eliminate barriers impeding LGBTQ student development
and achievement” (p. 37). An important step in creating an affirming environment is facilitating contact with other LGBTQIA+ youth and adults.
School counselors can establish peer-based support groups for LGBTQIA+
students, such as Gay and Straight Alliance Clubs (GSA). Topics to discuss
include identity development, bullying, community support, self-esteem, and
coping strategies (ASCA, 2016; Singh et al., n.d.). There are many resources
for starting GSAs and tips on handling school or community resistance (e.g.,
www.aclu.org/lgbt-rights/how-start-gay-straight-alliance and www.glsen.
org/jumpstart). Research shows that the presence of GSAs in schools is a
protective factor for LGBTQIA+ youth (Russell & Fish, 2016). When counselors facilitate a positive and safe school environment, LGBTQIA+ students
are more likely to remain in school, increase their resilience, and overcome
challenges hindering their success (Singh et al., n.d.). Counselors are obligated
to send a strong message that anti-LGBTQIA+ speech and harassment will
not be tolerated. School counselors should advocate for inclusive curricula
and help to cultivate culturally competent teachers. It is also important that
counselors advocate for the rights and safety of LGBTQIA+ youth, address
discrimination, and provide reputable resources and referrals (ASCA, 2016;
Singh et al., n.d.).
5.
Working with families. As LGBTQIA+ children express their sexual orientation and gender identity at earlier ages than in past years, researchers have
noted the critical role that family acceptance or rejection plays in the health
and well-being of these children. Families’ responses to children’s coming out
vary greatly, with differing levels of acceptance, rejection, or ambivalence.
Families that are rejecting at first usually become less rejecting over time;
therefore, counselors should provide families with accurate information to
help them to be supportive, regardless of their reaction (Substance Abuse and
Mental Health Services Administration [SAMHSA], 2014). Family rejection
is associated with higher levels of negative health issues (e.g., depression,
substance abuse, and suicidal ideation) in LGBTQIA+ youth. When parents
respond in a supportive way, youth demonstrate greater well-being, higher
self-esteem, and decreased risk for depression, anxiety, substance abuse,
and suicidal thoughts or behaviors (SAMHSA, 2014). Supportive families
and positive relationships with caregivers are strong protective factors for
LGBTQIA+ youth.
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SAMHSA (2014, pp. 8–11) identified the following key approaches for working
with parents and families of LGBTQIA+ youth:
•
View families as allies and respect their cultural values by providing information, education, and support that resonate with them (SAMHSA, 2014).
•
Provide families with respectful language to use regarding sexual orientation
and gender identity. Information and resources are available at the Family
Acceptance Project site: familyproject.sfsu.edu
•
Provide a safe, validating environment for families to “tell their story” about their
concerns for their LGBTQIA+ children and create a strong working alliance.
•
Educate families on the impact of rejection. Most families do not wish to intentionally harm their children. It is important to help families understand that
although they may believe they are being caring and loving when they try to
convince their children to change their sexual orientation or gender identity,
children often experience this as rejection or abuse (Ryan, 2009).
•
Educate families about the impact of accepting and supportive behaviors, which
are strong protective factors against serious health risks in LGBTQIA+ youth.
Parents help their children build resilience by the way they treat them and
can be supportive of their children even if they feel their identity is “wrong”
(SAMHSA, 2014).
COUNSELING CHILDREN WHO ARE VICTIMS
OF BULLYING OR HARASSMENT
Bullying, a type of peer victimization, is one aspect of school violence. Olweus (2013)
defines bullying as behavior that has three distinct criteria: “intentionality, some
repetitiveness, and imbalance of power” (p. 756). Typically, the behavior is intended
to cause harm or discomfort to the target. Traditional bullying includes physical
threats, physical violence (e.g., hitting), sexual comments, theft, rumors, and ridicule
(Page, Daniels, & Craig, 2015). Cyberbullying may involve posting embarrassing
pictures on social media or spreading lies or derrogatory information through
technology. Although traditional bullying is more prevalent than cyberbullying,
victims are usually bullied in several settings. Regardless or the type of bullying,
peer victimization is associated with lower academic performance and higher
truancy rates (Wormington, Anderson, Schneider, Tomlinson, & Brown, 2016).
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Furthermore, bullying is related to poor self-esteem in victims, and both victims
and bullies may face serious long-term consequences. Bullies face the risk of criminality and antisocial behavior as adults; long-term outcomes for victims include
depression, substance use, and adjustment disorders (Olweus, 2013).
CHARACTERISTICS
Typical outcomes for students who experience bullying, violence, or harassment
include depression, isolation, frustration, and reduction of investment in school
work. Moreover, school violence affects anyone who is exposed, not just victims and
perpetrators (Page et al., 2015). The physical (e.g., level of disorder in school, safety)
and social (e.g., engagement, feeling supported by teachers) aspects of the school
environment influence school violence.
Bullying is also known to contribute to actual and averted school shootings.
Daniels and colleagues (2010) provide insight into factors that are instrumental in
averting school shootings. The most prominent is categorized as school conditions.
This category includes a safe school environment that promotes optimal learning,
watchfulness and presence of school personnel, dignity and respect, school climate,
boundaries, positive relationships among staff and with students, and good rapport with students. According to Daniels and colleagues (2010), maintaining an
open, trusting relationship with all students was “one of the most essential roles
in preventing the plotted rampage” (p. 86). School belonging can be defined as
having “positive relationships with both peers and adults in the school context, as
well as perceived feelings of safety and belonging at school” (Daniels et al., 2010,
p. 4), and is comprised of emotional engagement, positive perceptions of school
climate, and a sense of school connectedness (Wormington et al., 2016). Fortunately,
school belonging can be cultivated, so it may be helpful to specifically target school
belonging when implementing interventions to prevent bullying and harassment.
The following section is relevant for helping children who are victims of bullying
and harassment.
INTERVENTIONS
Intervening for bullying and harrassement begin with prevention. Counselors who
work with young victims can use the Owleus Bullying Prevention Program (OBPP),
an evidenced-based program that has shown positive results in reducing students’
involvement in bullying and anti-social behavior (Bowllan, 2011; Owleus & Limber,
2010). The goals of the program include reducing exisiting bullying problems among
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students, preventing new bullying problems, and achieving better peer relationships
(OBPP, 2018).
When moving beyond prevention, interventions should take a multilevel approach
that focuses on bullies, victims, bystanders, and the entire community/school
(Ziomek-Daigle & Land, 2016). Proven interventions aimed at improving school
climate and making bullying socially unacceptable include programs delivered in
classrooms as a part of the classroom guidance program, small group counseling,
and individual counseling. One such evidenced-based program is Sources of Strength
(SOS, 2015) which aims to prevent bullying, suicide, and substance abuse. SOS assists
institutions, such as schools, to create peer social networks to change the culture
around seeking help and to create connections between youth and caring adults.
Ziomek-Daigle and Land (2016) encourage the use of Adlerian-based, small group
counseling, where members learn to invest in the social interest of the group and the
setting (residential treatment, school, etc.). While lunch time is not the ideal time for
school counselors to offer psycho-educational small groups, “lunch bunch” groups
(Ziomek-Daigle & Land, 2016, p. 307) can provide opportunities for diverse groups
of children and adolescents to come together to interact, share, and connect. Lunch
bunch groups can also provide an opportunity for victims of bullying to connect to
the counselor, thus forming a protective factor of a caring adult.
Finally, for younger children, individual counseling approaches, such as play
therapy and creative interventions like puppetry, art, drama, music, are effective
in helping victims of bullying and harassment deal with the fear, depression, and
isolation often associated with being bullied.
COUNSELING GRIEVING CHILDREN
AND ADOLESCENTS
Children and adolescents experience grief and loss for a variety of reasons. Although
typically associated with death, loss can also occur when a child moves or changes
schools or ends a friendship. Young clients experience loss and grief if a parent is
incarcerated, deployed, or injured in an accident, or if their parents separate and
divorce. Grief can also be associated with a celebratory event, such graduation, because
it involves a transition and a change in routine and relationships (Vernon, 2019).
Due to their developmental understanding of the grief process and their psychological development and maturity, children and adolescents often need therapeutic
support for this normal and natural process. Although the focus of this section is
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on counseling children and adolescents who are grieving a death, the interventions discussed can be applied to a variety of situations involving grief and loss in
young clients.
CHARACTERISTICS
Childhood grief differs from adult grief because cognitive development influences
a child’s understanding of death as well as the grieving process. Children and adolescents generally do not experience the intense and sustained emotional response
seen in adults. Rather, they often display intermittent sadness and may complain
more of physical issues (Sherner, 2015). The following describes a general pattern of
the development of the understanding of death and the associated grieving process.
Children from birth to 2 years old do not have an understanding of death. However,
they may react to the absence of a caregiver by increased crying and disruptions in
eating or sleeping. They may also react to caregivers’ grief emotions (Sherner, 2015).
Children ages 3 to 6 still do not understand that death is final and often exhibit
magical thinking: that if they are good enough, the deceased will come back. Because
they are not able to verbalize their feelings, they will likely express them through
aggression, physical issues, or sleep problems (Sherner, 2015).
Children between the ages of 6 and 12 understand the permanence of death, but
they are curious about what happens to the body when someone dies. By the age of
10, they understand that everyone dies eventually. Their reactions to the death of a
loved one may include guilt, anger, or anxiety about their own death. Children may
exhibit changes in behavior or peer relationships or demonstrate fear of abandonment and clinginess (Sherner, 2015).
Adolescents understand the concept of death, but they often have not developed
adequate coping skills. It is possible they will react with conduct problems, such
as impulsive behavior, anger, or substance use. Adolescents may have difficulty
accepting support from family members and may want to spend more time either
with friends or alone (Sherner, 2015).
Children and adolescents may experience grief differently when it is associated
with death by suicide than with other kinds of death, especially if the suicide was
completed by a family member or close friend. Research has shown that children
who must deal with suicide are at risk for several negative consequences (Cerel &
Aldrich, 2011). They face the additional challenges of trying to understand why the
loved one or peer chose suicide, as well as dealing with the stigma associated with
suicide. Reactions to suicide can include increased suicidal ideation and attempts,
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nicotine and marijuana use, binge drinking, and serious physical aggression. Overall,
suicide-bereaved children and adolescents seem to experience greater internalized problems, such as depression, anxiety, and PTSD (Cerel & Aldrich, 2011). The
combination of how the child perceives the suicide, the family environment, and
communication surrounding the death affects how young clients react, according to Cerel and Adlrich (2011). The most important message to communicate to
suicide-bereaved children is reassurance that someone is available to attend to their
physical and emotional needs.
ASSESSING GRIEF
Webb (2010) recommends that counselors complete an assessment to inform counseling and treatment. The assessment involves three groups of factors: individual
factors; factors related to the death; and family, social, religious, and cultural factors.
Individual Factors
Individual factors include the child’s age (developmental stage, cognitive level, and
temperamental characteristics), past coping and adjustment experiences, hobbies
and interests, medical history, and past experiences with death and loss. The level of
attachment or bond the child felt to the deceased will influence the intensity level of
the grief. Children with fixed mind-sets may have a more difficult time processing
their emotions than children with growth mind-sets.
Death-Related Factors
Death-related factors include the type of death (anticipated or unexpected), the perceived degree of pain suffered by the deceased, the presence of violence or trauma
associated with the death, contact with the deceased (was the child present at the
death), attendance at memorial ceremonies, an opportunity to express goodbyes,
and the relationship to the deceased (Webb, 2010). Children may demonstrate more
intense responses upon learning that someone died unexpectedly as opposed to
when the death was anticipated. Webb (2010) recommends explaining to children
what funerals or memorial services are like and giving them the choice of whether to
attend. Children ages 6 to 11 can express their goodbyes concretely, such as writing
a letter or planting a tree in memory of the deceased (Sherner, 2015).
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Familial, Social, Religious, and Cultural Factors
Counselors who work with bereaved children must take into account the influence
of nuclear and extended family influences, school and peer influences, and religious
and cultural influences that shape belief systems around death and loss. Information
in these areas can lead to insight about assets that strengthen a child’s ability to process and cope with a loss as well as to insight about factors that may be hindering a
child’s ability to process and cope with a loss (Webb, 2010).
Familial Factors
The family environment will impact the child’s grieving process. It is important to
understand how the family is grieving the loss, if there is stigma around the death,
how the family has approached the death or loss, if death had been discussed with
the child prior to the loss, what the family’s level of comfortability is with regard
to discussing death, and to what degree the family will be emotionally available to
help the child process the loss (Webb, 2010).
Social Factors
A child’s peer group is important at all ages, but it becomes even more influential
during adolescence and can affect the way in which he or she processes and express his
or her grief. If grieving children and adolescents do not feel accepted or understood
by their peers, counselors need to help them feel that they are not alone. Webb (2010)
recommends asking if the child knows anyone his or her age who has experienced
a loss or if the child want peers to know about the death.
Religious and Cultural Factors
Religion and culture often have both formal and informal messages regarding
death and grief. Children are often taught explicit beliefs that may be considered
either protective factors or maladaptive beliefs. It is important to understand their
religious or cultural beliefs about death, afterlife, or spirituality and to understand
traditions and the role of religion in the child’s life regarding processing a loss
or grieving a death. Webb (2010) recommends asking about the client’s religious
beliefs regarding death and afterlife (if the young client is religious), whether
the client has expressed thoughts/feelings about these beliefs with regard to the
present loss, or if the client participated in cultural/religious traditions or rituals
related to the death.
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Worden (2018) provides the following guidelines for counselors to help children
and adolescents work through grief:
1.
Help young survivors actualize the loss by encouraging them to talk about
the facts surrounding it.
2.
Help them to identify and express feelings such as anger, guilt, anxiety, and
helplessness. This might be done through art, music, bibliotherapy, puppets,
play media, or drama.
3.
Help young survivors learn to live without the deceased by fostering decision
making and problem solving.
4.
Help them to find a sense of meaning in their changed world by getting involved
in meaningful activities, memorializing the deceased in some way, exploring
how they are different because of the loss, and focusing on ways to rebuild
their sense of self-efficacy.
5.
Help young survivors find a new place in their life for the lost loved one that
allows them to move forward in life and form new relationships.
6.
Allow them time to grieve by explaining that grief takes time.
7.
Normalize grief behavior by reassuring them that what they are experiencing
is normal.
8.
Reassure them that not everyone grieves in the same way, even within the
family.
9.
Build trust, then help them examine their defenses and the effectiveness of
their coping mechanisms.
10.
Make appropriate referrals if some need special interventions to cope with
the loss.
INTERVENTIONS
One of the most commonly used task models for grief is Worden’s (2018) tasks of
mourning, which describes four tasks that must be accomplished before a survivor
can feel as if he or she has a new state of balance or normalcy: accept the reality
of the loss, work through the pain of grief, adjust to a life in which the deceased is
missing, and find an enduring connection with the deceased while moving ahead
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with a meaningful life. Counselors can structure interventions to help young clients
work through these four tasks.
Accepting the Reality of the Loss
Children and adolescents need to understand what has happened. Counselors can
encourage caregivers to explain the circumstances of the loss to answer children’s
questions. When talking to a child about death, adults should be specific, honest, and
concrete, and should answer the child’s questions as clearly as possible (Willis, 2002).
To help families cope during this task, counselors can give caregivers resources
that explain how to talk about death with children. Valuable resources include the
Dougy Center (dougy.org) and the National Child Traumatic Stress Network (nctsn.
org). It is important to discuss with caregivers ways that children might react to
this information. Advise caregivers that sometimes children and adolescents will
avoid talking about their loss or behave as if nothing happened. Counselors need
to reassure caregivers that this is normal. Bibliotherapy is beneficial for helping
children understand death and grief. Two recommendations include Why Would
Someone Want to Die? (Schmidt, 2007), and When a Friend Dies: A Book for Teens
about Grieving and Healing (Gootman, 2010).
Working Through the Pain of Grief
To help children accomplish this task, counselors can use a variety of individual
counseling techniques. McFarland and Tollerud (2009, p. 285) suggest these:
•
Complete sentence stems such as, “The memory that I like best about my loved
one is when we …”; “I’m glad my loved one and I got to … .”
•
Write a journal, story, book, or letter to the deceased about happy and
sad memories.
•
Make a memory mobile depicting memories about the deceased (Vernon,
2009, p. 157).
Adjust to an Environment in Which the Deceased Is Missing
When children lose a significant person in his or her life, they will need support to
adjust to a new environment without that person. This may include accepting new
bedtime routines if the loss involves the parent responsible for bedtime, developing
new friendships if the loss involves the loss of a friend, or developing new routines
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around the home if the loss involves a sibling. Play is an avenue of healing for grieving children. Through play, children can exercise control over their grieving and
process environmental changes. Counselors can use drawings, sand, or puppets to
assist children in processing their grief.
Find an Enduring Connection With the Deceased While Moving Ahead
With a Meaningful Life
This task involves being able to allow for thoughts and memories of the deceased
that lead to more pleasurable feelings and experiences such as new relationships.
Children working on this task can serve as resources for children who are working
on earlier tasks. Offering support to those working on the earlier tasks of mourning
can help children working on this task integrate the loss they suffered and begin to
get on with their lives (Yalom & Leszcz, 2005).
Bereavement groups are helpful in facilitating the grief process. Worden (2018)
recommends groups with a focus on emotional support. Children who have experienced a loss may feel different from their peers, so being a member of a bereavement
group allows them to experience the curative factors that small groups offer (see
more on curative factors in chapter 12). Siddaway, Wood, Schulz, and Trickey (2015)
reported positive results from child and adolescent groups that included creative
activities, such as creating a storyboard of their experience (life before the death,
the death itself, and how life is following the death). These groups included three
primary components: memory activities, information and meaning making, and
fostering coping and resilience using cognitive behavioral strategies.
It is inevitable that children and adolescents will face some type of loss in life.
When they do, facilitating “an approach that involves calmly presenting the reality
of the situation, answering questions honestly, helping them find support so they
don’t feel different, and acknowledging that their grief will be different from adults’
grief will assist them in dealing with loss in ways that build resiliency” (McFarland
& Tollerud, 2009, p. 286). With this understanding, counselors can provide interventions that decrease children’s exposure to stressors following a loss, strengthen
their protective factors, increase resilience, and improve coping skills.
TAKE-AWAYS FROM CHAPTER 10
As we conclude this chapter, we would like to refer to the short vignette at the beginning of the chapter and share both what was learned from working with Oliver, as
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well as a technique that was effective. As the counselor, I (Chris) quickly observed
that Oliver was functioning from a fixed mind-set; that is, he had decided that since
he was not successful at eating, there would be no way he could be successful at
other skills such as basketball. Through an REBT lens, Oliver’s self-talk included
phrases such as, “I can never be good at basketball,” or “Everyone is better at basketball than me.”
What I learned from my work with Oliver is that young clients who possess a fixed
mind-set require constant “proving” of intelligence or ability, which often results
in them not trying new things because a failure would prove inadequacy. The tape
measure worked well to creatively address how Oliver’s fixed mind-set was keeping
him stuck in a place he may regret later in life. I also learned the importance of
combining REBT with a growth mind-set approach to teach Oliver that when we
struggle with one part of our life, it doesn’t mean we can’t learn from that struggle,
try new activities, and learn when we make mistakes.
After reading this chapter, you now should be more knowledgeable about these
key points:
•
The concept of resilience and how to foster it in children
•
Protective factors and ways in which to foster it in young clients
•
The difference between a fixed mind-set and a growth mind-set
•
How to recognize and challenge a fixed mind-set in young clients
•
Specific interventions that promote resilience, grit, and growth mind-set
•
Specific challenging circumstances children and adolescents may experience
and effective interventions for addressing these challenges
HELPFUL WEBSITES
Resilience Guide for Parents and Teachers
www.apa.org/helpcenter/resilience.aspx
Welcoming Schools
www.welcomingschools.org
Preventing Suicide Among LGBTQ Youth: The Trevor Project
www.thetrevorproject.org
Olweus Bullying Prevention Program
olweus.sites.clemson.edu
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PRACTICAL RESOURCES
Creating Safe Space for GLBTQ Youth: A Toolkit
www.advocatesforyouth.org/storage/advfy/documents/safespace.pdf
The World Professional Association for Transgender Health (WPATH). (2011).
Standards of care for the health of transsexual, transgender, and gender
nonconforming people. (7th ed.). www.wpath.org
Mealtime Hostage (for parents struggling with children with
feeding disorders)
mealtimehostage.com
My Army One Source: U.S. Army deployment support handbook: Children
and youth
www.myarmyonesource.com/default.aspx
REFERENCES
American Academy of Child and Adolescent Psychiatry. (2017). Children and divorce.
Retrieved from https://www.aacap.org/AACAP/Families_and_Youth/Facts_for_Families/
FFF-Guide/Children-and-Divorce-001.aspx
American Counseling Association (ACA). (2009). ALGTIC competencies for counseling
LGBQIQA. Retrieved from https://www.counseling.org/docs/ethics/algbtic-2012-07
American Psychiatric Association (APA). (2013). Diagnostic and statistical manual of mental
disorders (5th ed.). Washington, DC: Author.
American School Counselor Association (ASCA). (2016). The school counselor and LGBTQ
youth. Retrieved from https://www.schoolcounselor.org/asca/media/asca/PositionStatements/PS_LGBTQ.pdf
Anderson, N. K., & Nicolay, O. F. (2016). Eating disorders in children and adolescents.
Seminars in Orthodontics, 22(3), 234–237. doi:10.1053/j.sodo.2016.05.010
Armstrong, L. L., & Manion I. G. (2013). Meaningful youth engagement as a protective
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CHAPTER 11
Counseling At-Risk Children
and Adolescents
Jennifer E. Randall Reyes and Monica Leppma
LEARNING OBJECTIVES
1.
To describe how trauma negatively impacts developing children and adolescents, increasing their chance of engaging in risky behavior
2.
To describe how to counsel at-risk children and adolescents using a four-stage
approach
3.
To describe culturally appropriate interventions that meet at-risk clients’ needs
with creativity, compassion, and caring
A
mon asked if he could speak with me (Jennifer) away from the rest of the
group. Over the last 8 weeks working with him in a juvenile justice setting, I
knew that he rarely asked for additional one-on-one interaction beyond his
group counseling sessions. When he came into my office that afternoon, he said he
needed help figuring out how to let go of guilt. I remained curious in my response,
asking in a neutral tone if he wanted to give me any more information so I could
help. As Amon sat across from me in my office, he said in a quiet voice that when he
was jumped into his gang he had to take part in a robbery, which meant carrying a
handgun. He was having a hard time letting go of the guilt he felt with the intrusive
images of an elderly couple frozen in fear, handing over their valuables. He said part
of his current charges stemmed from this incident, including multiple other traumatic scenarios in which he had to act in ways he now regretted. I realized in that
moment that this was probably beyond Amon’s self-reported guilt and had reached
the level of a trauma response.
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I wholeheartedly wish I could say that Amon is an outlier in my almost 15 years of
working with at-risk children and adolescents. Sadly, that is not the case. Increasingly,
his story is becoming the norm. There are two primary components to this chapter that
serve to illustrate why this is the case. The first is understanding the scope of the crisis
facing at-risk children and adolescents who do not have access to resources, which puts
them at a developmental disadvantage. The second is a model for addressing this crisis
in your own communities as social advocates. To do that, you must first understand
the historical significance of an at-risk designation and what that looks like in modern
society. The data, research, and statistics presented are by no means a definitive guide
and should only serve as a starting point for your own study into how the community
or school system in which you will ultimately practice are shaped by these factors.
In the previous chapter, you read about a variety of challenges children face, yet
in many of those situations, they have stable housing and people to care for them.
In this chapter, you will learn more about the most vulnerable populations of children and adolescents, where poverty and the ensuing drug epidemic disintegrates
the family system and creates new norms for families, such as grandparents raising
their grandchildren. The interventions described in this chapter address both social
advocacy and crisis counseling, with a focus on immediate stabilization and the
mitigation of further trauma. The overarching goal of this chapter is to shift your
thinking when you encounter particularly challenging children and adolescents
from wondering what is wrong with them to wondering what might have happened
to them. Read about one professional’s perspective on working with this population
in the “Voices From the Field” sidebar.
VOICES FROM THE FIELD—PROFESSIONAL
I ask my clients, “You know that not everyone’s life is like this, right?” Their norm
is not the norm of the general population. How many kids go home and fix their
own dinner? How many kids are parenting parents? We have to be their support
instead of writing them off and looking down at them. We have to stop and see
our place in this by asking where we failed them. When considering the individuals I work with who have been charged with committing a capital offense, I
believe society has failed them in one way or another.
—Deb, PsyD., trauma therapist
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DEFINING AT-RISK YOUTH
We need to begin with a working definition of at-risk youth. Kamenetz (2015) graphed
the evolution of this term that began with the phrase “juvenile delinquent,” then
changed to “dropout,” and shifted to “at-risk,” with the possibility for a strengthbased term such as “opportunity youth” to eventually take the place of “at-risk”
altogether. “At-risk” was a term that began to appear in the education literature in the
mid 1980s as more children and adolescents, both culturally and economically, were
vulnerable and incapable of living productive, independent lives as adults without
significant additional resources through social service prevention and intervention
services to be successful in both school and beyond (Kamenetz, 2015). For the purposes of clarity, we use the term “at-risk” throughout this chapter, even though we
agree with Kamenetz’s reflections on seminal literature (Placier, 1993) that saw the
potential negative implications of using “at-risk” as an overarching label that could
be too vague for effective use in guiding social policy efforts.
Two factors have fueled the current reality for at-risk children and adolescents.
The first is the deinstitutionalization of the mental health field over the last half of
the previous century. Deinstitutionalization means using the least restrictive environment possible in meeting the needs of those with severe mental illness, rather
than relying primarily on hospitalization in psychiatric wards (Doroshow, 2016). The
second factor is the pervasive rates of traumatization of children and adolescents.
The following section describes how the Adverse Childhood Experiences study
(ACE) has changed the way we look at trauma.
DEFINING ADVERSE CHILDHOOD EXPERIENCES
Given the high number of at-risk youth you will work with, primarily as a direct
result of the trauma they have experienced, it is important for counselors to be
aware of the Adverse Childhood Experiences study (ACE) and its implications. The
ACE study (Felitti et al., 1998) began as a research effort to better understand the
“long-term relationship of childhood experiences to important medical and public
health problems” (p. 246). It became a building block for future research, such as the
Philadelphia Urban ACE survey, to investigate the link between increased negative
childhood experiences to a decrease in mortality across the lifespan. In essence, those
who experience several ACEs are more likely to live shorter lives. This is staggering
in light of the authors’ explanation of this correlation:
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The linking mechanisms appear to center on behaviors such as smoking, alcohol, and drug abuse, overeating, or sexual behaviors that may be consciously
or unconsciously used because they have immediate pharmacological or
psychological benefit as coping devices in the face of the stress of abuse,
domestic violence, or other forms of family and household dysfunction.
High levels of exposure to adverse childhood experiences would expectedly produce anxiety, anger, and depression in children. To the degree that
behaviors such as smoking, alcohol, or drug use are found to be effective as
coping devices, they would tend to be used chronically (Felitti et al., 1998,
pp. 251–252.)
Typical questions that you ask a client to determine his or her ACE score focus
on whether clients had to deal with any of the following three categories of adverse
experiences: abuse, household challenges, or neglect. Let’s take a closer look at how
the ACE study defined adverse childhood experiences. The following examples of
adverse experiences are from the original ACE study questions and the outline produced for the Philadelphia Urban ACE survey and are published by the Research
and Evaluation Group at Public Health Management Corporation (2013, pp. 5–7).
ABUSE AND NEGLECT
The unfortunate reality is that child maltreatment in the form of neglect, as well as
physical, sexual, or emotional abuse, is very prevalent. In fact, during 2016, child
protective service agencies received an estimated 4.1 million referrals that involved
7.4 million children. Although the majority of children suffered from neglect (74.8%)
and physical abuse (18.2%), many of them suffered multiple forms of maltreatment.
It is estimated that in 2016, 1,750 children died from abuse or neglect, and 70% of
these child fatalities were younger than 3 years of age. Furthermore, 78% of these
fatalities involved at least one parent (U.S. Department of Human Services, Children’s
Bureau, 2018). Federal legislation provides guidelines for identifying and defining
child abuse and neglect: “Any recent act or failure to act on the part of a parent or
caretaker which results in death, serious physical or emotional harm, sexual abuse
or exploitation”; or, “[a]n act of failure to act which presents an imminent risk of
serious harm” (U.S. Department of Health and Human Services, 2010).
While it is beyond the scope of this chapter to thoroughly discuss abuse and
neglect, it is important to remember that child abuse occurs throughout the world
at all socioeconomic levels (UNICEF, 2013). There are multiple family characteristics associated with child maltreatment, including substance abuse, stress, family
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structure, and parents who were themselves victims of abuse (Henderson & Thompson, 2016). Although some children are resilient, many suffer long-term negative
consequences of abuse and neglect, including depression, suicide attempts, addiction,
eating disorders, panic disorder, post-traumatic stress disorder, and others (Springer,
Sheridan, Kuo, & Carnes, 2007).
HOUSEHOLD DYSFUNCTION
While there are numerous indicators of household dysfunction, there are some which
contribute more significantly to early childhood trauma and therefore, higher ACEs
scores. Children living in homes where domestic violence and substance abuse are
prevalent, where a household member has a mental illness or has a family member
in prison, are at higher risk of developing chronic adult diseases, including addiction
and mental illness themselves.
Domestic Violence
Domestic violence also contributes to childhood trauma and, unfortunately, is often
overlooked, denied, or excused. Oftentimes children get caught in the middle if the
abusive parent or caretaker threatens to take the children away or harm them. Children who witness domestic violence may see the actual incident or hear the threats
and the fighting. They may also observe the aftermath of abuse such as bruises and
broken bones. They are fearful and anxious and are always on guard (Domestic
Violence Roundtable, 2018). They do not feel safe and worry about the victim who is
being abused, as well as their siblings. They feel powerless, vulnerable, and isolated.
Because their family may appear normal to the outside world, they are often confused
and ashamed or blame themselves, thinking they should be able to do something to
prevent the violence. Long-term consequences include a predisposition for violent
and abusive behavior as adults, higher risk of alcohol and drug abuse, increased risk
of psychological problems, and PTSD. Living in a home where domestic violence is
prevalent is the number one reason that children run away from home (Domestic
Violence Roundtable, 2018).
Substance Abuse
According to Sacks, Murphey, and Moore (2014), children and adolescents exposed
to drug and alcohol abuse in the family was one of the most commonly reported
ACE in every state. Children growing up in alcoholic families are at greater risk
for mental and physical health problems and are more likely to have learning
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difficulties (Henderson & Thompson, 2016). Oftentimes, their physical and emotional needs are neglected and they adapt the following roles to cope with their
parent’s addiction: enabler (supports the addict, minimizes the addictive behavior), hero (overly responsible), scapegoat (takes blame for problems that were not
his or her fault), the lost child (scared, isolated, ignored), placator (the pleaser),
or the mascot (plays the role of the clown to promote cohesion) (Sciarra, 2004).
Children living in addicted households may feel guilty, anxious, embarrassed,
confused, angry, and depressed. The long-term consequences of growing up in a
family caught up in the cycle of addiction include a higher risk of children and
adolescents becoming dependent on drugs and alcohol and at greater risk for
behavioral and emotional problems.
Mentally Ill Household Member
Children who live with a family member who is depressed, mentally ill, or suicidal
live with confusion, anxiety, and vigilance. As is the case with other types of dysfunctional families, their needs are often neglected. They often feel ashamed about
their family and don’t feel comfortable inviting peers home, which can affect their
social development. They are at greater risk for problems later in life, including
emotional and psychological problems (Metha, 2017).
Household Member in Prison
When a parent, sibling, or caretaker serves time in prison or another correctional
facility, the entire family is affected. Traditionally the focus has been on the incarcerated family member, but it is important not to overlook the long-term negative
consequences for children and adolescents. They experience greater instability in the
family, which may lead to foster care placement. The stress resulting from imprisonment of a household member corresponds to the greater likelihood that teenagers
will engage in risky behaviors, including teen crime and pregnancy. Furthermore,
the economic strain and social stigma negatively impact youth (Dobbie, Gronquist,
Niknami, Palme, & Priks, 2018).
COMMUNITY AND ENVIRONMENTAL FACTORS
The Philadelphia Urban ACE study (Research and Evaluation Group, 2013) took
place in 2012 and expanded on the ACE study by surveying almost 2,000 adults in
Philadelphia to compare the initial ACE study findings (Felitti et al., 1998) to a more
urban and diverse population set:
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The study found that 40.5% of Philadelphia adults witnessed violence while
growing up, which includes seeing or hearing someone being beaten, stabbed
or shot. Over one-third (34.5%) of adults reported experiencing discrimination based on their race or ethnicity, while almost three in ten adults (27.3%)
reported having felt unsafe in their neighborhoods or not trusting their
neighbors during childhood. In all, over 37% of Philadelphia respondents
reported four or more ACEs (p. i).
The negative community and environmental events that participants reported
witnessing or experiencing included not feeling safe or not having people who
looked out for each other in the neighborhood (neighborhood safety and trust),
being bullied by a peer or classmate (bullying), seeing or hearing someone being
beaten up, stabbed, or shot in real life (witnessed violence), being treated badly or
unfairly because of race or ethnicity (racism), and being or having been in foster
care. The elements identified in the initial ACE study, combined with community
and environmental categories from the Philadelphia study, contribute to negative
outcomes for children and adolescents, discussed later in the chapter.
NATURAL DISASTERS
Natural disasters are sudden and dangerous events that occur in nature, such as
hurricanes, earthquakes, wildfires, and floods, and often result in mass destruction
and death. After a natural disaster occurs, whole communities can take a long time
to recover. Those affected are usually offered services for basic physical and emotional
needs directly after the disaster. In the long term, many of these services may not
be as readily accessible, even though the people affected may still be hurting and in
need (Powell & Holleran-Steiker, 2017).
Children may experience several stressors during and after a natural disaster,
including “fear of death or loss of a loved one, the loss of a home and community,
displacement to a strange neighborhood or school, and even separation from their
family” (Powell & Holleran-Steiker, 2017, p. 176). Increased anxiety is very prevalent,
as is loss of security.
MASS TRAUMA AND VIOLENCE
Incidents of mass violence are those caused by humans and result in trauma to an
entire community or even a country, such as terrorist acts, school shootings, or
war (Substance Abuse and Mental Health Services Administration [SAMHSA],
2018). Other types of mass trauma can result from fleeing a turbulent country as
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a refugee, asylum seeker, or immigrant. Children in these situations may experience exposure to violence, loss of their homes, detention, or separation from
their families (Leppma & Szente, 2014). Events of mass trauma and violence are
relatively rare in the United States; however, when such events occur, adults are
very interested in learning the details so the media outlets provide considerable
exposure and information (Hilt, 2013). Researchers have discovered that media
coverage of mass trauma and violence can generate the development of acute
stress reactions, PTSD, anxiety, and conduct problems in children (Comer, Bry,
Poznanaski, & Golilk, 2016; Hilt, 2013). Fortunately, despite the serious negative
outcomes associated with mass trauma and violence, most children’s symptoms
resolve after a few months (Comer et al., 2016). Resilient children with prosocial
skills (e.g., kind, helpful) often demonstrate no deleterious effects following such
events (Comer et al., 2016).
Children who experience any of these traumatic events demonstrate greater mental
health issues than those exposed only through the media. Factors that predict stress
reactions following traumatic events in children include level of exposure to the
traumatic event, level of distress (e.g., fear, helplessness, horror) at the time of the
event, family exposure, losing a loved one, and parents as first responders (Comer
et al., 2016). The first goal of interventions following exposure to major traumatic
events is to provide a safe space, ensure that basic needs are met, and develop rapport and trust; thus, it is important that counselors possess patience and empathy
(Yahav, 2011).
GENERAL INTERVENTIONS FOR TRAUMATIC EXPERIENCES
No single, trauma-based intervention will provide relief for every young client.
When working with children and adolescents who have experienced a traumatic
event, be it a mass trauma event or a single traumatic event, counselors should
be open to a variety of interventions. Research generally supports the use of eye
movement desensitization and reprocessing (EMDR) as well as cognitive behavior
therapy (CBT) (Grolnick et al., 2018) to help children after traumatic events. EMDR
requires specialized training before counselors can practice this approach. Counselors
must carefully consider the timing of trauma interventions, as well as the degree of
distress, developmental level of the child, and specific circumstances. Helpful CBT
interventions include teaching relaxation and self-soothing skills, teaching skills to
manage intrusive thoughts, and correcting any irrational beliefs resulting from the
trauma (Baggerly & Exum, 2008).
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Another evidence-based treatment, trauma-focused cognitive behavioral therapy
(TF-CBT), is designed to treat children between ages 5 and 17 who demonstrate
trauma-related symptoms (Page, Daniels, & Craig, 2015). Treatment consists of
three phases: a stabilization phase, a trauma narrative phase, and an optional
integration/consolidation phase (Cohen & Mannarino, 2015). During the TF-CBT
process, counselors must demonstrate empathic attunement by deeply hearing
and validating the children’s needs, communicating understanding of their struggles and distress, and affirming their strengths and victories (McCrea, Guthrie,
& Bulanda, 2016). Once the child feels safe, validated, and understood—which
requires multiple sessions—the counselor can then collaborate with the child on
developing helpful and healing ways to modify the trauma-related cognitions
(Page et al., 2015). One example of a healthy cognition is, “I can talk about the
[trauma] without crying” (Cohen & Mannarino, p. 560). It is important to note
that when children and adolescents continue to experience trauma (e.g., living in
a violent community or remaining at-risk while in treatment), counselors should
allow them to determine their own pace in creating and processing a meaningful
trauma narrative. Counselors must learn to enter the child’s world “completely”
(McCrea et al., p. 11). Good resources that provide more information on TF-CBT
are: musc.edu/tfcbt; nctsn.org; and musc.edu/cpt.
Regardless of the specific trauma experienced by young clients, play therapy is
beneficial for children between the ages of 2 to 10, since children often recreate their
trauma repeatedly through play (Baggerly & Exum, 2008). Counselors can facilitate
therapeutic play to help children process their trauma and regulate symptoms, progress developmentally, build resilience, and increase their sense of safety. Baggerly
and Exum (2008) also suggest the following play therapy activities: “(a) play a game
of identifying indicators that they are safe at the present time, (b) draw a picture of
a safe place, and (c) develop a safety plan for future disasters” (p. 86). Counselors
should note that regardless of age, it is therapeutically beneficial to provide an avenue
for “healthy enjoyment” to children and adolescents as part of treatment (McCrea,
et al., 2016).
Bibliotherapy can also be useful in helping young children process trauma. One
book we recommend is Brave Bart: A Story for Traumatized and Grieving Children
(Sheppard, 1998). This book provides a good discussion guide that counselors can
use to help children process the story, as well as their own experiences.
A specific intervention for natural disaster recovery, the Journey of Hope (JoH),
was created in response to gang fights that were associated with Hurricane Katrina in
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2007 (Powell & Holleran-Steiker, 2017). This program consists of eight sessions that
are implemented once or twice a week. The focus is on interactive learning to build
coping skills after a disaster has occurred. Topics discussed include “safety, fear, anxiety, anger, grief, bullying, self-esteem, and self-efficacy” (Powell & Holleran-Steiker,
p. 178). This approach is child centered and gives children the opportunity to voice
their trauma-related emotions. Counselors also provide psycho-education regarding common reactions and coping strategies. Activities used to promote protective
factors include group problem solving, cooperative games, and discussions about
how to effectively express emotions (Powell & Holleran-Steiker).
ADVERSE CHILDHOOD EXPERIENCES
AND DEVELOPMENTAL CONSEQUENCES
Risky health behaviors, housing instability, low socioeconomic status centered in
high-crime neighborhoods, lack of availability of nutritious foods and the resultant
nutritional deficits of an overreliance on ultra-processed foods and sugar-laden drinks
are all byproducts of family systems fraught with trauma (Monteiro, Moubarac,
Cannon, Ng, & Popkin, 2013). In addition to these factors, adolescents, developmentally, are intrinsically more reliant on their peers for advice rather than their
family members, and peer influence can often be negative. Furthermore, adolescents
behave impulsively because their brains are not fully developed, especially the prefrontal cortex, which is the band of tissue responsible for higher-order thinking and
decision making. As a result, they aren’t able to think through the consequences
of drinking alcohol with friends and then getting into a vehicle with an impaired
driver. This puts teenagers at higher risk just by the fact that their underdeveloped
brains make it nearly impossible to limit impulsive behavior fully until the mid-20s
(Siegel, 2014). An excellent resource to educate about the brain is a graphic novel
entitled Neurocomic (Farinella & Roš, 2013), which can be used with children and
adolescents (and even adults) to explain the brain, its systems, and how trauma can
negatively impact those structures when they are developing.
If we’ve done our job so far in this chapter, you are beginning to realize that there
is a very high rate of co-occurring traumatic experiences. Felitti and colleagues (1998)
reported that children and adolescents who experience four or more ACEs are four to
12 times more at risk of experiencing alcoholism, drug abuse, depression, and suicide
than those with lower ACE scores. Also, there is a strong correlation between high
ACE scores and greater risk for disease, disability, or early mortality (Baldwin, 2018).
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Additional research added to the ACE study literature has shown that adults who suffer
from a serious mental health condition often first experience signs of these mental
health problems as children or adolescents (Kieling et al., 2011). Kessler and colleagues
(2010) additionally found that children who are exposed to childhood maltreatment
and have a parent or caregiver in their home with a severe mental illness are more
likely to experience these conditions chronically across their adulthood. Therefore,
we need to consider depression, anxiety, and addiction as symptoms of trauma.
SYSTEMIC SOCIETAL CONSEQUENCES THAT
­CONTRIBUTE TO TRAUMA
Children and adolescents may experience many different types of traumatic events,
as we have outlined thus far in this chapter. Systemic consequences can happen
when the social systems in which children and adolescents grow up are themselves
traumatic. Negative outcomes may arise even if a child does not experience the
traumatic event first-hand. While there are a number of common outcomes from
experiencing traumatic events, individuals respond differently based on their context
and characteristics. Children are one of the most vulnerable populations during
and after a systemic traumatic event because they are still developing their sense of
security in the world, they have limited coping skills, and their responses depend a
great deal on the psycho-emotional functioning of the adults in their lives (Comer,
et al., 2016; Grolnick et al., 2018). Several factors influence the potential for a child
developing psychopathology after a traumatic event, including the degree of exposure to the event, the child’s developmental level, gender, temperament, home and
social environments, parental influence, and resources or deficits the child may have.
Protective factors may include support systems, healthy coping mechanisms, and a
sense of control. Children with more protective resources may have a greater ability
to adapt to situations after a traumatic event compared to children who have fewer
resources. At-risk children often have limited protective resources; therefore, it is
important for counselors to identify and build on strengths and resources. “Specific
coping strategies can include positive thinking (growth mindset), emotional regulation, acceptance and emotional expression” (Powell & Holleran-Steiker, 2017,
p. 177). In our discussion of ACEs and the system societal consequences associated
with at-risk children and adolescents, we now focus on low socioeconomic status,
racism, the school to prison pipeline, and foster care, as well as specific suggestions
for addressing these societal problems.
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LOW SOCIOECONOMIC STATUS (SES)
With shifting family structures, such as those described previously in chapter 10,
come shifting family financial struggles. Many families who experience separation, or
divorce or who never have support from a second parent or partner often experience
financial strain that ultimately impacts the children involved. Low socioeconomic
status (SES) essentially means that people are lacking access to the financial resources
needed to live healthy, productive lives. Low SES matters when considering negative
outcomes for at-risk children and adolescents. Think of the fact that low SES has
been linked to everything from higher rates of childhood and adolescent obesity
(Vieweg, Johnston, Lanier, Fernandez, & Pandurangi, 2007) to stronger links to
mental disorders such as anxiety, depression, antisocial disorders, and attention
deficit disorders (Miech, Caspi, Moffitt, Wright, & Silva, 1999).
The stark reality of these higher instances of serious physical and mental health
concerns illustrate why this chapter is included in a text on counseling children
and adolescents. The designation of being at-risk implies an immediate need to
intervene with this population before they become the next generation of adults
suffering from the same concerns facing their parents. Breaking the generational
cycle of poverty could mitigate what the Equality of Opportunity Project has called
the fading American dream when minority boys growing up in low SES areas are
working less as men than the girls who grew up similarly do as women (Chetty,
Hendren, Lin, Majerovitz, & Scuderi, 2016). This data stands in contrast to traditional reports that contend that the wage gap and childrearing are factors in women
working less than their same-aged male peers. When race is also taken into account,
the unacceptable reality is that “lower income families are more likely to be black,
and black men are more likely to be incarcerated than white men” (Chetty et al.,
2016, p. 3). Chetty and colleagues (2016) suggest that young men growing up in
environments of concentrated poverty could account for their propensity to turn
to criminal activity.
Interventions for Low SES
The West Virginia Center for Children’s Justice first piloted the Handle with
Care program in 1993, working in a school that had 93% of its children coming
from low SES families (WV Center for Children’s Justice, 2018). As the model
has expanded across West Virginia and into other states, the consistent chain
of events goes as follows: A law enforcement officer trained to identify children
at the scene of a traumatic event (e.g., a domestic violence incident, witnessing a
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violent act, a drug raid) notifies the child’s school via a confidential fax or e-mail
expressing that the school should handle that child with care the following day.
The teachers and staff are then notified, and since they too have been trained to
recognize the impact of trauma, they refer the at-risk children and adolescents to
their school counselors. School counselors then have the capacity to work with
these children, and through networking in their communities, they can refer
parents to trauma-informed counseling. When school counselors use these types
of multi-tiered systems of support, they become more effective advocates for students in at-risk communities.
RACISM
Racism is an attitude of discrimination, prejudice, or hatred toward others because
of their race or ethnicity. According to Korous, Causadius, and Casper (2017), it
results in “unfair, negative, and differential treatment” (p. 90) and lack of opportunities due to the belief that certain racial, ethnic, or culture-based groups are
inferior. Racism can occur on an individual level, as well as institutional (e.g.,
schools or workplace) and cultural levels (e.g., public policy). Research indicates
that minority children experience increased racism as they grow into adolescence.
By the age of 10, children begin to understand that racial/ethnic differences are
associated with societal and systemic disparities (Umaña-Taylor, 2016). Racism is
correlated with a number of negative consequences, such as depression, anxiety,
academic problems, substance use, physical aggression, and low self-esteem. These
negative outcomes have been noted across race/ethnicities and all developmental
levels (Umaña-Taylor).
Interventions for Racism
Given it is beyond the scope of this chapter to provide a comprehensive list of
effective strategies to combat racism, it is our hope that you seriously consider
what can be done to combat racism. According to Pederson, Walker, Rapley, and
Wise (2003), “[T]he literature suggests that the best possible strategy for combating
racism is multi-faceted, and developed in accordance with the specific and local
circumstances of the community for which it is intended” (p. 5). These authors
also suggest that since racism exists at both individual and systemic levels, that
interventions be delivered at the individual, institutional, and cultural levels. Individual interventions may include providing knowledge about racial and cultural
issues, dissonance (creating a situation where individuals are asked to behave in
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ways incompatible with their preconceived beliefs), and teaching empathy toward
minority groups. Interpersonal strategies that can be used in institutional and
cultural levels include intergroup contact (creating environments where conflicting
groups have contact with one another), providing consensus information (allowing
opposing groups to learn that not all their beliefs are shared), and dialogue (creating safe spaces for opposing groups to share thoughts and beliefs) (Pederson
et al., 2003).
SCHOOL TO PRISON PIPELINE
In the last few decades, the risk of dropping out of school prior to successful high
school completion was the primary concern when working with at-risk adolescents.
However, at-risk youth are now growing up in communities where the more accurate
concern for practitioners is how to be effective social advocates when dropping out
of school often escalates to being placed in juvenile justice facilities and eventually
prison. The “school to prison pipeline” (STPP) is a term used frequently in research,
policy discussions, and social advocacy efforts to encompass the systematic oppression
happening in our educational system (Skiba, Arredondo, & Williams, 2014). Conceptually, the term provides a framework for better understanding the phenomenon
happening across the United States as disproportionate numbers of minority and
at-risk youth are placed in juvenile detention facilities and often fail to return to
school (Nicholson-Crotty, Birchmeier, & Valentine, 2009; Skiba et al., 2014). Research
suggests that one possible answer to solving the STPP issue is an evaluation of the
discipline practices within school systems. There is a clear correlation between higher
rates of exclusionary discipline, such as suspensions (Nicholson-Crotty et al.) and
expulsions (Skiba et al.) in minority populations, with long-term negative consequences such as higher dropout rates, more juvenile justice referrals, and eventually
higher adult corrections placements. If we recognize that the STPP exists, and we
know that it disproportionately impacts children of color, the question becomes
not if, but how to integrate the research on exclusionary discipline use in schools
as a predicting factor of at-risk children and adolescents falling into this category.
Effective social advocacy can mean learning more about social issues with which you
may not be familiar. For example, are you aware that the United States still allows
children as young as 14 (Alexander, 2012) to be incarcerated in adult prisons? While
this section focuses on juvenile justice, please keep in mind that the United States
is the only remaining nation in the world that allows children to be sentenced to
life in prison for crimes committed while they were kids (Quandt, 2018). Engage
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in community action on these issues and empower clients to voice their needs in
ways that challenge the status quo. We will be discussing social advocacy more in
depth later in the chapter.
Interventions for the School to Prison Pipeline
Given the need to rethink discipline practices in schools and communities, counselors can become social advocates by engaging in restorative justice. Historically,
dealing with problematic behaviors in schools and communities has been addressed
by focusing on who is to blame and then dispensing punishment. In contrast, restorative justice refers to an innovative approach to addressing inappropriate behavior
that emphasizes repairing the harm done to people and relationships. According
to Hopkins (2003), restorative justice, and its principles and practices, “have the
potential to make significant contributions in making schools safer, happier places,
reducing exclusion and the need for exclusion, creating a culture of inclusion and
belonging, raising morale and self-esteem, raising attendance, tackling bullying
behaviours throughout the school community” (p. 28). Payne and Welch (2017)
note that the use of restorative techniques in response to violence and misbehavior
in schools has shown a reduction in student delinquency, improvement in academic
outcomes, and improvement in school climate.
Institutions that employ a restorative justice approach focus on answers to the
following questions: (a) What happened? (b) Who has been affected and how? (c)
How can we make this right? and (d) What have all parties learned that can be used
to make different choices next time? (Hopkins, 2003). Restorative justice involves a
process that often includes restorative enquiry, restorative discussion in challenging
situations, victim/offender mediation, community conferences and problem-solving
circles, restorative conferences, and family group conferences.
Additionally, in our work in the social justice system, we often found the following
simple intervention to be useful. Instead of beginning the counseling process by
asking what went wrong, our first priority in working with any youth in an out-ofhome placement, such as juvenile justice where the statistics point to higher overall
dropout rates, is to focus on protective factors they have available that we can build
on, such as asking about the quality of family relationships or peer social support
or skills or abilities. This simple intervention can also be applied in school settings
when, all too often, school and mental health counselors are called on to investigate
conflicts. Think through how you could tailor similar questions when you are working with at-risk children or adolescents who have been labeled “problem children.”
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Ask what the best part of their day is, who they look up to and why, or who or what
is their favorite teacher or school subject. Questions such as these provide valuable
information for treatment planning. Counselors can serve as the one voice that is
different in focusing on strengths first, building a therapeutic alliance, and then
getting to the behavioral aspects. If you first focus on behavioral aspects, you will
come across as yet another person trying to figure out what they did “wrong.” Read
about one client’s perspective on being the “problem child” in the “Voices From the
Field” sidebar.
VOICES FROM THE FIELD—CHILD
I was the problem kid starting in kindergarten. I didn’t want to be bad, but I was.
I was mad all the time. Really mad at myself because I loved school! I got so mad
when I couldn’t stay out of trouble for one day. When I got adopted, my adoptive
parents said I should go see my school counselor. I finally got some help from her
and I learned I didn’t have to be the bad kid anymore. Now I don’t get in trouble
as much. It’s for normal stuff now when I have to go to the principal’s office, like
talking too much. Not like the stuff I used to do like stealing food at lunch or
getting into fights with kids who teased me.
—Jade, age 9
Focusing on protective factors helps you craft your work together in two directions. First, you can use their answers to see who and what they aspire to be.
What are their goals and dreams? What gaps exist that might impede them from
reaching their goals and how can resources be pooled to bridge those gaps? This
can be a powerful question-driven intervention to get clients focused on goals and
strength-based behaviors versus focusing on past failures. Secondly, counselors
should advocate for at-risk clients within the school and community because this
could shape the future direction of what happens after the client’s time in juvenile
justice is over.
Another intervention to battle the school to prison pipeline is the Positive Action
(PA) program (Lewis et al., 2013; Schmitt, Flay, & Lewis, 2014). The PA program
is a comprehensive school-based, social emotional learning and health promotion program that has been used in various educational settings from preschool
to high school. While this resource is not a definitive solution, it is at least one
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evidence-based prevention model that can be implemented within the school setting.
Outcome studies of PA thus far have demonstrated significant decreases in discipline referrals in the settings utilizing this system. Implementing evidence-based
systems that promote prosocial behavior is a good starting point in mitigating the
damage to children identified as “problem kids” in the school system. Materials to
accompany this program include grade-specific lessons with additional creative
interventions for educators, school counselors, community, and family members.
Additional information is listed at the end of this chapter.
FOSTER CARE IN THE UNITED STATES
No discussion of at-risk youth would be complete without acknowledging foster
care as one of the most common out-of-home placements experienced by children
and adolescents when they have experienced neglect, physical abuse psychological
maltreatment, or sexual abuse. Almost half a million children were in the foster
care system in the United States in 2016 (U.S. Department of Health & Human Services, 2017). In 2016 alone, over 4.1 million referrals were made to Child Protective
Services in the United States, which ultimately led to almost 200,000 referrals to
foster care (U.S. Department of Health & Human Services, 2017).
Interventions for Foster Care
I (Jennifer) wish I had had the Foster Parent Survival Guide (FPSG) (Vicario,
Hudgins-Mitchell, and Corbisello, 2013) when I worked as a treatment coordinator
and provided in-home services to foster parents over a decade ago. The FPSG is a
comprehensive workbook for foster parents who struggle to understand the behavioral
and emotional responses of the children in their care. The FPSG demonstrates how
trauma negatively impacts developing brains, along with a succinct overview of problematic behavior and how to effectively intervene. One simple intervention suggested
in the FPSG for foster parents to use with children is to say, “This is a safe place and
I won’t let anyone (name the behavior you want the child to stop doing [hit]) you, so
I can’t let you (name the behavior again [hit]) because this is a safe place” (Vicario
et al., 2013, p. 10). Twice in this sentence a child is receiving the message that this is
a safe place. There is also a clear message about where the foster parent has to draw
a behavioral boundary line and why, which could easily be translated into school
settings for school counselors working with students, teachers, and administrators to
create effective behavioral interventions rather than punitive disciplinary measures.
See the “Now Try This!” sidebar and challenge yourself to use this strategy!
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NOW TRY THIS!
Practice using the safe place statement outlined to name a specific behavior
that you want to work on for creating a boundary in either a child or adolescent’s home or school setting. The example from the Foster Parent Survival
Guide is, “This is a safe place and I won’t let anyone hit you, so I can’t let
you hit anyone either because this is a safe place.” Consider how might this
work with at-risk children. How could you modify this statement with developmentally appropriate language to use with at-risk adolescents?
COUNSELING AT-RISK CHILDREN AND ADOLESCENTS WITH TRAUMA SYMPTOMS
Let me introduce you to the Marcus, whom I first met when he was 17 years old and
living in a juvenile justice facility. In his short lifetime, he had witnessed domestic
violence in the home, and both of his parents had been incarcerated. He had grown
up moving at least once every 6 months, and oftentimes he did not have enough to
eat. After listening to his story, I realized that his ACE score was the highest I had
ever seen. He was therefore in the worst risk bracket, as a 14-year-old, of developing
life-threatening and chronic diseases as an adult. His life expectancy would be lower
that his same-aged peers with lower ACE scores. The focus of my career shifted in
that moment as I wondered what I could do for clients like Marcus to influence
their future in a positive direction. His case was further complicated by the multiple
symptoms he was experiencing as a result of his early childhood trauma—depression,
anxiety, and substance abuse. You’ll read more about Marcus as we discuss how to
address his symptoms of trauma.
Refer to the “Dialogue Box” sidebar for a typical exchange between a counselor
and an at-risk client, which illustrates how we need to be curious, rather than accusatory, regarding the situations we often suspect at-risk children and adolescents
such as Marcus are in so that we can be helpful.
As you have read in this chapter, the unfortunate reality is that children and
adolescents are not immune from trauma. Exposure to traumatic experiences often
puts young clients at risk for anxiety, depression, addiction, and suicide because
they lack effective coping skills to deal with their overwhelmingly negative circumstances. Felitti and colleagues (1998) discussed adopting primary, secondary, and
tertiary prevention strategies to include “prevention of the occurrence of adverse
childhood experiences, preventing the adoption of health risk behaviors as responses
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DIALOGUE BOX
CLIENT: This is stupid. I don’t need counseling.
COUNSELOR: Well, we have at least the next hour together. How
do you want to use it?
CLIENT: Look, you seem nice. I’m just not going to do this because
my mom is really the one that needs to be in here.
COUNSELOR: Would you be surprised to know that I hear that a lot?
CLIENT: No, I wouldn’t. Kids get it, that parents are messed up.
COUNSELOR: Got it. So, what particular flavor of messed up is your
Mom that she needs to be here instead of you?
CLIENT: She just doesn’t get it. She thinks it’s okay to check out and
then say sorry, so it’s okay.
COUNSELOR: What is one thing you wish that your mom knew
about your life, since she doesn’t get it?
CLIENT: I just wish she’d take back some of the adult stuff I have to
do to take care of myself.
COUNSELOR: What kind of adult stuff?
to adverse childhood experiences during childhood and adolescence, and finally,
helping change the health risk behaviors and ameliorating the disease burden among
adults whose health problems may represent a long-term consequence of adverse
childhood experiences” (p. 254).
School counselors in particular are often on the front lines of the trauma epidemic
in this nation. To meet that enormous need, the American School Counselor Association (ASCA, 2016) developed the school counselor and trauma-informed practice
as a position statement for their members to “understand the impact adverse childhood experiences have on students’ academic achievement and social/emotional
development” (p. 66). Their call to action is a standardized approach to providing
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trauma-informed practice in schools, but also in communities where school and
mental health counselors assume social advocacy roles.
Referring to the case of Marcus, let’s now move through clinical presentations of
trauma outcomes you might see. We will use his case to demonstrate practical ways
to work with clients experiencing depression, anxiety, and substance abuse as a result
of childhood trauma. We will also discuss non-suicidal self-injury and suicide. It is
beyond the scope of this chapter to address other negative trauma outcomes, such
as eating disorders, early sexual activity, and other psychological and emotional
problems, so we encourage you to educate yourselves on these factors.
DEPRESSION
Depression can lead to serious social and educational impairments and, if untreated,
puts children and adolescents at higher risk for suicide. One of the first things I
(Jennifer) did with Marcus was to administer the Beck Depression Inventory, second
edition (BDI-II), since this version expanded on the original adult population and
can be used for adolescents as young as 13. His elevated score indicated that he was
clearly experiencing depressive symptoms. Rather than using this information to
tell him he was clinically depressed, I used it to inform his understanding of what
his answers showed me in terms of how his presentation was similar to other clients
I had seen in the past. Marcus reflected in our closing session months later that he
appreciated the fact that I hadn’t jumped to give him a diagnosis and had instead
showed him that he was not alone in what he was feeling.
According to Waite and Shewokis (2012), there is a strong connection between
childhood trauma and the adult depression being reported by low-income ethnic
minorities such as Marcus. What he needed was a way to combat the trauma
symptoms that were showing up as depression before he became yet another adult
experiencing the long-term negative impact of early childhood trauma. EMDR
therapy was the core of the therapeutic work I did with Marcus, in addition to the
following interventions that seemed to impact his overall health and wellness.
Adventure therapy (AT) uses, “adventure experiences provided by mental health
professionals, often conducted in natural settings that kinesthetically engage clients on cognitive, affective, and behavioral levels,” (Gass, Gillis, & Russell, 2012,
p. 1). Having been trained as a wilderness instructor working in private adventure
therapy programs, I already knew how effective AT could be with at-risk children
and adolescents. Even though Marcus was in a juvenile justice setting, I was able to
integrate adapted AT techniques into our work together. Marcus jumped at every
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opportunity to be outside, and we spent many individual sessions hiking through
the terrain on the facility’s property while he discussed his life. I found that being
in more natural settings for Marcus meant fewer of the typical complaints about
depressive symptoms, such as not having any energy or motivation for simple tasks.
Instead, his focus was on letting go of his idea of his limitations and contemplating
what his future could be. This was a doorway into an entirely different way of life
in which Marcus could achieve hard things, such as climbing a mountain, and then
using that accomplishment as an analogy when he was facing a proverbial mountain
of homework to complete to catch up to his grade level.
ANXIETY
Marcus was easily one of the most anxious at-risk adolescents I had ever worked with
at that time. He could not sit still, so I had no trouble imagining what had been so
challenging for him in classroom settings when I observed him in our first session
as he sat rapidly shaking his leg and chewing through his pencil. I abandoned the
idea of having him complete another assessment and instead read the Beck Anxiety
Inventory (BAI) to him. The BAI was a good fit because Marcus was 17 when I began
working with him; however, when working with younger at-risk clients, I would
suggest using the Beck Youth Inventory (BYI), since you then have access to five
separate measures that can be administered quickly and effectively for depression,
anxiety, anger, disruptive behavior, and self-concept.
Marcus’s score on the BAI was also not surprising, but again I reminded him that I
had seen similar scores before and explained how common it was for people who had
grown up in similar situations as his to have high scores on depression and anxiety
screenings (Chu, Williams, Harris, Bryant, & Gatt, 2013). Using assessments that
can be scored immediately in session is a good way to build rapport, which is at the
heart of your therapeutic relationship with clients. I also learned from Marcus to
stop handing an assessment to clients and instead read it to them aloud so I could
observe their nonverbal communication when responding to questions. For instance,
even though Marcus’s scores were elevated, I could tell from his body language that
he was doing his best to minimize his symptoms. His downcast eyes, inability to
make good eye contact, shrunken shoulders, and shaking leg were all indicators I
would have missed had I given him these assessments beforehand and simply had
him fill them out prior to the session.
Marcus said during his initial session that the one thing he felt he was really
good at was art. I asked a few probing questions to learn which medium and style
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he preferred. In one of our earliest sessions, Marcus came in my office to find me
organizing my art cart. I had purposefully taken everything out of the cart and
placed art supplies on available surfaces. The chair clients typically sat in was covered
in different types of pencils and pens, including some charcoals since Marcus had
said he wanted to learn more about them. Marcus showed the first signs of interest
as his eyes widened when he saw the art supplies. I asked him if he would be willing
to draw things that worried him. He sat quietly in front of a blank piece of paper
for several moments and I didn’t intervene, because even when it is uncomfortable
for you, it is important to let the client be silent. He finally picked up a red marker
and began to draw concentric circles, each connected and growing thicker than
the last, as his drawing expanded outward from the center of the page. His artwork
from that day became the focal point of our sessions and a graphic treatment plan
for our therapeutic work around his anxiety.
Next, we will discuss substance abuse and the generational impact of this disease
on families, as well as the increased risk for children and adolescents to develop their
own substance abuse disorders, as Marcus did.
SUBSTANCE ABUSE
The first step in treating substance abuse is to get as accurate an assessment as possible
of the reality of your client’s substance abuse. This can be difficult when working with
at-risk children and adolescents. While the Adolescent Substance Abuse Subtle Screening
Inventory (SASSI-A2) is an effective assessment tool to use as a substance abuse screening for both mental health and school counselors working to provide trauma-informed
practice, it is also a good idea to ask some version of the following question in an intake
session to quickly understand the scope of a child or adolescent’s drug and alcohol
use: “Tell me how many drinks you would have on a typical night out partying? 15?
20?” Clients typically respond with a shocked expression and quickly deny that they
ever drink that much! However, counselors often get incredibly surprising follow-up
statements when clients answer that it is more like eight to 10 beers. An intentional
overestimation yields more accurate and honest information than asking about alcohol
use in an open-ended fashion. Also, remember that the ACE study includes several
questions about exposure to drug and alcohol abuse that may render an additional level
of risk even if your client is denying current substance use or abuse.
Marcus did not respond initially to my attempts to assess his level of substance
abuse. He told me war stories of his past use, such as waking up in an ER after drinking alcohol for the first time as a toddler. Yet, he was reluctant to discuss the details
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of what his life looked like now. I was therefore surprised early on in his time at the
juvenile justice facility when he volunteered for the family sculpture activity (Miriounis,
2017). Using members of his unit in a group counseling session on addiction, Marcus
moved the most physically intimidating boys into a line facing the rest of the group.
He then took the smallest member of the group and moved him to the furthest corner,
away from the line of bigger and stronger boys. His next move surprised me as he
moved his closest friend on the unit to stand with his arms stretched out in a sign of
protection, standing in front of the smallest boy crouched in the corner. Even though
I had given no directions about using verbal instructions, Marcus told his friend not
to let anyone get near the small boy in the corner, no matter what. I stood humbled
and amazed as he took a few steps back away from the sculpture and said that this is
what every “family system” he had been a part of over the last several years looked
like; lots of physically aggressive and potentially violent adults standing on one side
trying to make Marcus do stuff he did not want to do, like treatment. He went on to
say how hypocritical he thought it was to have to go to drug counseling when most
of the adults in his life were hooked on opiates too. I watched as his unit members
nodded their heads in agreement with his statements, finally realizing the scope of
the opioid epidemic in their communities. They could all identify with these broken
family systems that were adversarial versus supportive, as reflected by their family roles.
NON-SUICIDAL SELF-INJURY (NSSI)
Non-suicidal self-injury (NSSI) is when clients participate in any form of self-harm,
such as intentionally cutting themselves, burning themselves, or mutilating their
body intentionally as a way of dealing with overwhelming emotional pain. NSSI is
hard to assess given that many clients hide this type of behavior. Therefore, even the
International Society for the Study of Self Injury (ISSS) gives competing numbers but
generally notes that between a quarter and half of all adolescents had self-harmed
within the last year (“Fast Facts,” 2018).
Let me (Jennifer) share the case of Heather, a 13-year-old American Indian female
who was my client at a residential treatment center. She had been cutting herself,
primarily on her arms, since she was 8 years old. Most of my young clients would
do their best to cover their self-inflicted wounds or scars, while Heather said she
wanted the world to see how mad she was all the time. This was new for me. She
was mad, not sad? She was angry at not being able to control her mother’s drinking
and angry that both older brothers had dropped out of school, leaving her to parent
her mother. Heather described in detail her process of waiting patiently until the
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end of the day when she could sneak to the bathroom for a few minutes to cut and
know she would not be bothered. She used a razor blade each time. I noticed that
her breathing and heart rate picked up as she started to describe seeing blood start
to form on her wounds. She said this was the only way she knew to “let it out without
going totally nuts.” I worked hard to keep my face as neutral as possible to let her
know that I would not judge this behavior, because even though it was maladaptive,
she had found a way to cope with a tough situation. My work with Heather was about
acknowledging her struggle, hearing her story, and only then working with her to
shift toward adaptive coping mechanisms.
Counselors who work with NSSI often rely on interventions that teach replacement
behaviors as substitutes for actual injuring behaviors. The specific interventions
that worked for Heather were substituting various colored lip liners to mark her
arms, which allowed her to continue showing the world how mad she was without
cutting. She created beautiful depictions of dark images to illustrate her pain and
resentment. Heather also agreed to plunge her hands all the way up to her elbows in
ice water as another replacement behavior that would provide a physiological shift.
Neither replacement behavior worked all the time, but I remained nonjudgmental
when asking if she had tried either of her identified alternatives first.
Additional common replacement behaviors include encouraging self-injurers
to wear rubber bands around their wrists and snapping themselves when they feel
the need to self-harm. Counselors can also teach clients to take a single piece of ice
and hold it tightly against their skin. Clients often report that these type of replacement behaviors can serve as more socially acceptable ways induce the pain they are
attempting to replicate.
Through Heather’s case, you get a glimpse into what it looks like to counsel
someone using NSSI as a coping mechanism. Even though she was not expressing
suicidality, I would also have ensured that she was aware of resources to contact in
case of crisis for future reference. Regardless of whether you are working with NSSI
or suicide ideation, it is imperative that you educate your clients, their families, their
teachers, and their communities about the 24/7 hotlines, National Suicide Prevention
Lifeline (1-800-273-8255) (TALK), and reinforce that they can call or send a text to
741741 at any time, day or night, if they are in crisis and need immediate support.
The CDC (2018) suggests five additional steps to help someone at risk:
1.
Ask someone you are worried about if he or she is thinking about suicide.
2.
Keep them safe; reduce access to lethal means for those at risk.
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3.
Be there with them; listen to what they need.
4.
Help them connect with ongoing support, such as the Lifeline (1-800-273-8255).
5.
Follow up to see how they’re doing.
SUICIDE
Suicide is the third leading cause of death for children ages 10 to 14, and the second
leading cause of death for adolescents and young adults ages 15 to 24 (CDC, 2017).
Of those who committed suicide, 54% did not have a known mental health condition
at the time of death (CDC, 2018), which means that counselors must get better at
recognizing the warning signs, assessing effectively for warning signs, while educating the communities and family systems we serve about suicide. This section gives
an overview of how to achieve this triad of recognition, assessment, and education.
Recognition
Sommers-Flanagan (2018) outlined eight pre-suicide dimensions as an alternative
to the traditional thought that risk factors are adequate predictors, given that a risk
factor could serve as a protective factor for another. These dimensions can serve as
a foundation for counselors to construct their own tools and techniques for greater
awareness in the populations they serve for those who could be at risk for suicide.