Category Archives: counseling science

June 2, 2008 · 5:24 am

Practicum and Ethics Monday: Deficient Trainees


Since both of these classes are in progress here at Biblical, I thought I’d bring up a rather touchy subject: impaired students. Ruth Palmer, Gwen White, and Walter Chung (a Biblical grad!) all of Eastern University have recently published an article in the Journal of Psychology and Christianity(2007, 27:1, 30-40) entitled, “Deficient Trainees: Gatekeeping in Christian Practitioner Programs.”

Palmer et al surveyed profs in master’s level counseling related departments at Christian colleges and universities to find out, 1. what percentages of students were perceived by the profs to be professionally deficient, to have received help or dismissal. 2. Whether or not the schools have formal gatekeeping procedures. 3. Whether senior level faculty and junior level faculty perceive the pressures of dealing with impaired students differently, and in part, 4. Whether views on grace, calling, and gifting have any effect on how faculty respond to deficient students.  Their study replicates one done on secular campuses.

Before I mention the results, it would be good to consider why this is important.

1. Because faculty are obligated to protect the public. The authors quote from the ACA code of ethics, “Counselor educators, throughout on-going evaluation and appraisal, are aware of and address the inability of some students to achieve counseling competencies” (ACA, 2005, Section F.9.b) (p. 31). This is a relatively new topic amongst programs. Previously, we merely taught our students but it was up to licensing boards to weed out incompetency. Not so any longer. And rightly so is this change. We have an obligation to remediate problems before sending folks to their fieldwork sites. When we bless a student with an internship, we are saying they are ready to work at an entry level. When we find students with significant relational, behavioral, motivational problems prior to graduation, the authors remind us that the data are “strongly linked to subsequent poor performance in clinical work. (p. 31)

2. Counseling programs tend to attract people who are working out their problems. In fact, the authors point to a study that reported first year counseling students showing more severity of problems on MMPI scales. (This may be partially explained away by the common tendency of students to think they have all the disorders of the DSM). While this isn’t necessarily a bad thing (could mean that students are more likely to be cognizant and empathetic to the trials of life), it becomes a problem when said students are either unaware of the extent of the problems, unwilling to work on these problems, or so overwhelmed in the moment as to not have the capacities to deal properly with the problem. I find most students very committed to personal growth and change. There are those, however, who are so desirous of the prestige of the position or of looking good that they cannot bear to admit their flaws. The authors point out the crux of the problem. “…there is a tendency of impaired students to resist submitting to ‘the very therapeutic process through which they wish to lead others,’… (p. 31)

3. Finally, turning a blind eye to student problems and/or mismatch in skill/profession/calling is akin to walking around the man and left to die on the side of the Jericho road (Luke 10).

Results of the study? The authors got responses only from 1/3 of the surveyed professors (the surveyees should be ashamed at their lack of cooperation with this important study! They ought to know better having all been through programs that value the research question). But from respondents they found,

  • Faculty of CCCU estimate an avg. of 10.9% of impaired students in their program (SD=9.89; I would have liked to see the modal response since the range was from 0% to 50%!! reported). This fits with the prior secular program survey.
  • Interventions with these impaired students only happens about 50% of the time (again a big SD with response rates ranging from 0% – 100% (yeah, right!)). 38% of faculty reported interventions less than 20% of the time.
  • What are some of the bigger reasons for not addressing these matters formally? Fears of lawsuits, institutional pressures (we need students to survive!), fear of poor teaching evals by junior faculty, and inadequate administrative support.
  • They suggest the need to have departments talk regularly about policies, students, and the need to follow-up with potential or actual problems.

Do we ever have impaired students at Biblical? Of course. But I am determined at dept chair to help those in need find help. I remember being a student at another seminary and seeing those that EVERYBODY knew should never be a pastor or a counselor and yet NOBODY (student or teacher) said a word. So, we have 6, 12, and 18 month evals collecting data from the student, profs of each class, peers, mentors, and supervisors to help catch a remediate problems when they exist and to encourage on-going personal growth even when they don’t exist. It still surprises me when I find counseling students balking about getting some of their own counseling. We really do want to be the one who has it together, don’t we. Me included.

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May 19, 2008 · 10:05 am

Practicum Monday: Premature Termination in Counseling


Today in Practicum class we discuss matters around ending treatment or counseling relationships with our counselees. The one that causes interns most consternation is the premature termination by clients after only one session. The trainee is left to wonder why. “Did I fail to connect? Did I say something to offend them? What did I do wrong? Did they figure out I don’t know what I’m doing?” Usually, they report feeling like a failure. Here’s a secret: even experienced therapists feel this at times as well.

Well, let’s start with the murky data. Brogan, Prochaska & Prochaska (v. 36 (1999) of Psychotherapy: Theory, Research, Practice & Training, 105-113) report that various studies reveal a premature termination after just one session stands somewhere between 20 and 57%. Some 30-60% drop out before the counselor thinks they should. And a meta-analytic study (of 125 studies) reports a premature dropout rate of 47%. Even though our research in this area is still weak (we don’t really know what factors to use to report premature dropout), the numbers are pretty high.

So, why do people stop counseling before they should? Why do our clients not return? We really don’t know as much as we would like. We do know that individuals in certain demographics are more likely (lower SES, lower education, minority status) to drop out. But even here, we don’t really know why. Is it client-counselor mismatch? Lack of understanding of the process of counseling? Lack of hope?

We do know that several factors do NOT seem to relate to premature termination (therapy mode, setting, and ages of clients).

While our research is still cloudy, it makes sense to consider the combination of client factors (motivation for personal growth, ability to have insight), environmental factors (financial status, family support or detraction, cultural support), and counselor factors (capacity to empathize and connect with the client’s perceptions, diagnostic and listening skills).

Trainees can ask these questions in their postmortems:

1. Did we share an understanding of the type and severity of the problems?
2. Did I give evidence that I understand their experience (beyond saying so)?
3. Did I give some evidence of the path forward and hope for the future without overselling it?
4. Did I acknowledge potential pit-falls, hopelessness, fear?
5. Was my client the “customer” or was someone else demanding it (e.g. parent)?   

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May 12, 2008 · 5:29 am

Practicum Monday: Scott Stanley on Couple Conflicts


Last week in our staff meeting we listened to the end of Scott Stanley’s conference presentation on couples communication. You may remember I blogged previously on his funny but too-true analogy of dogs and marriage (We fall in love with the front end of the puppy/marriage, but they both have backs ends that need to be managed).

In this section of the presentation he makes this statement: events trigger issues. Couples tend to fight about events but really most conflicts are about issues that are deeper (e.g., Who gets the say around here, Do I have influence, Do you care, and other expectation clashes). The challenge is to get couples to see past events to the issues.

Problem: most couples only talk about issues during emotionally charged events. Why? It would be easy to say avoidance. But take that a step further. If the couple is no longer in conflict, why bring up something that is likely to trigger it? As Stanley says, “We’re really getting along right now, so I don’t want to screw it up by talking about a problem.” Seems good in the moment, but bad over time.

Stanley’s point is to deal with this problem by (a) handling events well (time out, staying in the moment, etc.), and (b) being proactive by maintaining safe, open communication about issues. This takes sacrifice, he says. Healthy sacrifice (not martyrdom) is pretty powerful and helpful in moving toward the desires of the other.

Here’s a couple of my thoughts:

Stanley has some great techniques and seems to have a good handle on what goes wrong in conflict. I think many couples can benefit from better care of the “back end” and making sure to remember and reinforce the front end as well. He rightly points out that we can easily miss the good sacrifices others do daily and then only recognize the good when it stops for some reason. If we’re not careful we take for granted the sacrifices of others and come to expect and even demand them as rights.

Stanley’s techniques seem not to work with couples where insight is low, trauma or violence has been a part of it, when folks have personality disorders, or when the couple are deeply entrenched in their bitterness towards each other. All events have meaning. The couple that is not willing to reconsider the meanings they apply to events (she is evil, that is why she leaves the kitchen that way), little couple work is possible. In fact, maybe even contraindicated. Techniques that should help become

weapons to hurt and destroy. Couple counseling is based on the capacity to observe self and other and to withhold judgment to see life from another perspective. Without this, it is hard to make much progress outside of painstaking experiential work.

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April 28, 2008 · 10:53 am

Practicum Monday: Potentially Harmful Therapies


I was perusing the Journal of Psychology and Christianity (27:1, 2008; pp. 61-65) this morning and saw Siang-Yang Tan’s mini article entitled, “Potentially Harmful Therapies: Psychological Treatments That Can Cause Harm.” He was working of a similarly titled article by the so-called Ralph Nader of Psychology, Scott Lilienfeld of Emory U. (in Perspectives on Psychological Science, v. 2:1, 2007, pp. 53-70).

Some therapies on the PHT list would not surprise you. For example, Tan lists re-birthing techniques where you wrap up your client in blankets put them between the therapist’s legs so they can be healed from their birth trauma. Sadly, a teenager suffocated not that long ago here in PA when an unlicensed person attempted this with her client. Also, Tan lists the use of hypnosis with those with Dissociative Identity Disorder (DID).

But, you may be surprised to find that Critical Incident Stress Debriefing (CISD) also makes the list of PHTs. CISD (aka CISM) has been used for years with police and fire fighters to help them debrief from traumatic experiences and the thinking is that this prophylactic intervention helps exposed individuals avoid problems such as PTSD.  But there is evidence that such care may not only not help some individuals, it might actually harm others by increasing their arousal and those inclined to be hyperaroused appear to do better with no debriefing. For more of a critique of debreifing see DeVilly, Gist, & Cotton’s 2006 article in the Review of General Psychology (10:4) entitled, “Ready! Fire! Aim! …”

While CISD is not without merit and not always harmful, its popularity and widespread use without careful analysis should give us pause.

What widely accepted methods of Christian counseling also have the potential for harm?

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April 21, 2008 · 5:43 am

Practicum Monday: Is conflict necessary in therapy?


In the latest edition of the Journal of Counseling Psychology (55:2, 172-184), Nelson, Barnes, Evans, and Triggiano have published an article on the inevitable conflict between supervisor and supervisee–what leads to it, how supervisors react to it as well as supervisor strategies for managing it.

But, these lines about therapy caught my eye:

It is likely that conflict is as difficult to manage in supervision as it is in psychotherapy. Yet addressing conflicts successfully can be a healing and educational venture. The work of “tear and repair” in therapeutic relationships suggested by Safran (1993) and Safran and Murran (1996, 2000) is thought to be critical to optimal outcome in psychotherapy. The capacity of therapeutic relationships to recover from relationship breaches is thought to enhance client trust that relationships can survive misunderstandings and disagreements as well as client confidence that he or she can successfully resolve them. A skillful therapist can guide a client through the process of accepting the therapist’s inevitable fallibility, thus enhancing client capacity to accept his or her own… (172)

What do you think? Is conflict necessary for healing? I think yes. Otherwise, the client and the therapist idealize each other and so become blind to reality.

However, not all relationship breaches are good and we don’t always respond well to them, making matters worse.

How do you feel about conflict with your clients? With your counselor?

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April 16, 2008 · 5:41 am

Integrative Psychotherapy XIII: Concluding Thoughts


We come to the concluding chapter of Mark McMinn’s and Clark Campbell’s Integrative Psychotherapybook. They remind us that it was their endeavor to detail their model of integration, psychotherapy, and Christian approach. By integration they meant that they wanted to thoughtfully integrate a variety of psychological theories (as opposed to mindless or even pragmatic eclecticism) as well as their theological views of persons. Their version of integration is best defined, so they say, by the term theoretical integrationism (TI). “[TI] occurs when a person begins with a particular theoretical starting point and then extends the theoretical base by incorporating one or more additional theories” (p. 386). What is the heart of the IP model found in this book? McMinn started with CBT and CT and has incorporated relational approaches more likely found in dynamic models of therapy. Campbell is reported to have begun with interpersonal and family models and incorporated and practiced CT. I would suggest that CT is the heart of the IP model with relational and interpersonal understandings of persons included. I would suggest that there is little evidence of family models in this book.

The authors make brief mention of their theological integration in this chapter. They admit that they take a rather narrow view of Imago Dei and apply that to personhood and psychotherapy by looking at the image of God through the lens of functionality, structure, and relationship.

IP attempts to address life both at the level of symptom reduction AND transformation. The authors recognize that many things lead to transformation–not just therapy. However,

“Psychotherapy is only one means of transformation, but in today’s society it has become an important and ubiquitous one. Even within the church there appears to be a strong and growing interest in counseling and psychotherapeutic ministries, though suspicions about psychology persist in many congregations and denominations. Church-based counseling ministries are now commonplace, most pastors and church leaders have a referral network of therapists in their community, seminaries offer courses and degrees in counseling, and support groups and peer-counseling ministries are being established in many churches. This trend is encouraging insofar as it helps the church care for whole persons as Jesus ministered to the spiritual, physical, relational and emotional needs he saw in others” (p. 388).  

Notice the word, “insofar” in the previous sentence. The authors see increased chance for harm if we “conflate” psychotherapy and the church. They are concerned about two problems: (a) making the gospel about us (self-actualization) instead of Jesus work, and (b) having untrained and undertrained individuals offering therapeutic help and so causing harm to vulnerable people. They do not want to see the Church compromised by becoming therapeutic nor do they want to see the profession of counseling dumbed down by removing the professional, academic, and scientific groundings.

Finally, they end the book by listing 6 ways their IP model is comprehensive: (a) includes both psychology and christianity, (b) consider multiple domains of persons, (c) multiple dimensions of therapy, (d) includes both scientific and relational approaches, (e) christocentric, and (f) usable with both christian and nonchristian clients.

So, now that we have concluded their book, what do you think? Did it make you more interested in viewing therapy through the symptom, schema, and relationship lenses? Did their model seem usable in your context? Were their Christian foundations necessary, or said differently, how did their Christian beliefs change how they function with clients? Would a Christian therapist who loves Jesus but sees their work as being a relational cognitive therapist act any differently? I’m curious if you have a reaction.

Some of my reactions:

1. This is probably the best Christian integrative book I have read. They work harder in this book to make sure that they acknowledge the all-too-common superficial use of Christian beliefs in building a model of care. They also display much humility and do not want the church to water down the Gospel. Therapy isn’t everything for them. Christianity is trump, in their eyes.
2. There is almost no negativity directed at any other model. Most of us use other models as foils for why what we do is better. I congratulate them on being able to map out a model without attacking others. When they do point out weaknesses, it is in their perception of the limits of cognitive therapy.
3. The book is now in need of a follow-up that more deeply illustrates case material. What does IP look like in an extended case study. I would love to see that as a follow-up text. What they did provide were little snippets that had a lot of realism to them. I just want more. Here’s one little question. Does Scripture only come into play at the symptom level of change? It seems to by the way they write and don’t write about Scripture. Does Scripture have anything to do with transformation and experience? Scripture is not merely a cognitive or intellectual enterprise (though we often use it this way).
4. I might quibble with them on their Christology, though I found their positions not quite clear and so may not differ as much as I think. Christ’s death and resurrection IS the power for change (2 Cor. 5:16f). His life does inspire us but we cannot love others merely because of his life. I think they might agree with this, but I’m left with confusion as to where they stand here.
5. As expected, this is a text for therapy trainees. It sets out boundaries for the profession. Lay and church leaders can learn from this model, say the authors, but ought to be careful not to function as a professional. Even though I am a professional and I have found in teaching counselors that it takes character, the Holy Spirit, skill acquisition, and much practice to be a wise counselor, I am always a bit troubled by the boundary setting. It seems we are trying to protect our own domain. I do think there are wise counselors who never had any academic psychological training. It may not be common, but let’s remember that pastoral care has been helping people long before clinical psychology developed into a discipline. I would have liked to see a bit more work in informing the reader (a psychology trainee) about the dangers in trying to function like a spiritual shepherd.
6. I’m in concert with their model as it functions in session. We are conduit for reconciliation. Therefor our working relationships matter almost as much as our words and interventions. When we can reduce symptoms of suffering, we should. But, we also recognize the insidious nature of sin in our lives and must seek transformation of our minds and experiences in submitting them to reality as seen through God’s eyes.

For those interested in Mark McMinn’s further work, you might check out his new book on sin, Sin and Grace in Christian Counseling (IVP, 2008). It is also written for the counseling practitioner.

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March 31, 2008 · 2:20 pm

Science Monday: The end of Psychopathology


No, we haven’t found the cure for psychological problems. We’ve just come to the end of the course today. We’ll be looking at the problem of Borderline Personality Disorder. In order to understand personality disorders, we need to have an adequate understanding of both biblical anthropology (who does God say we are) AND the self (how we experience ourself and the world and so develop a consistent identity). Given that we live in a fallen world where deception rules the day, it is helpful to see how we tend to develop our self identity.  One such theory is called Constructivist Self-Development Theory. In short, the authors suggest the self is made up of

1. Frame of Reference: (one’s identity, worldview, beliefs, etc.)
2. Self-capacity: (inner capabilities that allow the individual to maintain a consistent coherent sense of self and to manage emotions)
3. Ego resources: (ability to conceive consequences, set boundaries, and self protect–ability to develop interpersonal strategies)
4. Sense of safety: (self-perception, trust, control, and connection to others)

This theory (and I haven’t done justice to it in this small space) suggests that these 4 areas work to help people form cognitive schemas that enable them to interpret events and memories from past events).

I like the theory’s attempt to address matters of safety and internal resources. Some people seem to have an innate sense of organization, boundaries, and ability to manage emotions. Others struggle more. In both cases, we develop a coherent sense of self as we construct our sense of ourselves in the world. Those who grow up in more chaotic and destructive environments have a much tougher time getting a bead on themselves and others. The world just doesn’t make as much sense.

The problem is what is not said or explored. Frame of reference, in my opinion, comes not only from experiences but also from God himself (Romans 1). We construct our perceptions of self but not in a vacuum.

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March 26, 2008 · 3:15 pm

Integrative Psychotherapy XI: Relationship focused interventions


We’ve been following the development of the theory and application of McMinn and Campbell’s 3 tiered Integrative model of persons and change. Now, in chapter 10, we arrive at the deepest and least objective level of change that takes place in counseling: therapeutic relationships. While some problems can be dealt with through skills and behavior change and other problems can be dealt with by exploring core beliefs and schemas, there are some core or “soul” problems that are best handled by being in a healing relationship. We’ll get to what that means in a moment…

The authors begin to tackle the problem of personality disorders. They describe how we all have personality styles, how some of those styles turn into problems (unthoughtful engagements with others), and how some turn into full-blown disorders (“defined as consistent patterns of behavior, evident since childhood or adolescence, which impair social functioning and cause significant distress to self or others.” (320)).

Functionally, some people are unable to step back from their assumptions and schemas and consider alternative perspectives. Such a person experiences their life but has a hard time observing their life without being sucked into negative experiences (see inset on p. 322). The therapist’s job is to try to maintain a relationship, focusing on the here and now (the relating that is going on between the counselor and counselee) in order for the counselee to gain new experiences and thereby develop a greater capacity to step back and see self.  “The working assumption of relationship-focused IP is that relationships change people” (p. 324).

Then the authors give a little summary of key personality theory by reviewing Freud, Horney, Stack Sullivan, and family systems models regarding how interpersonal patterns develop. They conclude by saying that our interpersonal patterns, “are formed early in life as a means of reducing interpersonal anxiety, maintaining a consistent perception of self in relationship to others, and as a means of stabilizing family life” p. 331). 

McMinn and Campbell dig deeper to ask the question: how is it that these developing styles become rigidly used? How is that an early experience get “re-enacted” in adult life? They turn to 3 theories:

1. Interpersonal Process Approach. Unmet needs leads to anxiety which leads to internalizing negative feelings about the self which lead to treating others the same (ad nauseam). These interactions continue because they are familiar and they “work” for us by reducing anxiety (we can make sense of the world and they work to some degree).

2. Cyclical Maladaptive Patterns. A cycle develop that is played out in every relationship. These cycles are organized into 4 parts: acts of the self, expectations of others’ reactions, acts of others toward the self, and acts of the self toward the self (p. 335).

3. Reciprocal Role Procedures. As a person grows, they “develop more sophisticated ideas of where self ends and other begins. The growing child learns ways of relating with the other so as to maintain attachment between the I and the Thou….But each of these roles is reciprocal; that is, they are met with a response on the part of the other.”

Is there a Christian perspective on personality problems? The authors explain their take on the creation (that we are created to be in relationship) and fall (that because of our tendencies to use relationships for our own pleasures, self-deception, sins against us) we form patterns of how we see ourselves (usually victims). And finally, they briefly explore how redemption means experiencing safety and grace now in a manner to “reform faulty interpersonal patterns.”

My thoughts.Here the authors inject dynamic models of relating into the development of a mostly cognitive model–up to this point. They rightly recognize that we develop much of our sense of self in early stages of life and then cement those views in an on-going way–even when we hurt ourselves with those views. And true, we often see ourselves as victims. What is hard is to see that we are both victim AND victimizing at the same time. Unfortunately, they used up their space in the chapter in talking about how interpersonal processes can be broken without much theorizing about how and why present, positive interpersonal experiences change us and shape our constructs of self and why they change so slowly. It is somewhat easy to point out that our acting on and being acted on shapes us when we are vulnerable. But what happens in the now that enables us to open up and reconsider our identity without feeling like we lose ourselves?

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March 24, 2008 · 11:03 am

Science Monday: Easing the suffering in schizophrenia


While few outpatient, private practice therapists deal much with those diagnosed with schizophrenia, there are things therapists can do to ease the suffering of both client and family. Kim Mueser, a professor at Dartmouth Medical School has published a number of helpful research and popular writings designed to increase social and cognitive functioning and decrease family distress in people with schizophrenia. Click here for an Amazon.com list of his writings. His Complete Family Guide (#1 on the list) is probably the best though several other texts may be just as useful depending on the reader’s focus. And while medications are important in the treatment of schizophrenia, it is quite clear that when families and client learn to minimize family distress and conflict, they also reduce active psychotic episodes

—–

There are a number of interesting research angles on the pathways of Schizophrenia. One such hypothesis is that the croticostriatal loops do not work correctly in such patients. In lay terms this means that information doesn’t flow normally from the frontal lobe of the brain to some of the mid-brain structures and then back again. This seems to be part of the cause of apathy and lack of volition and/or planning. One wonders whether the longer time it takes for information to flow properly in order to make a decision or interpretation increases the likelihood of making random assumptions about the world. I know that when my children get stuck in a math problem, they are more likely to begin wild guessing to complete the task.  

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March 10, 2008 · 10:06 am

Science Monday: Child PTSD


Today’s psychopathology class focuses on child related problems. Given the societal focus on ADHD and Asperger’s, our class will hang out there. However, I want to bring to your attention some work in the area of family violence and childhood trauma reactions. Gayla Margolin and Katrina Vickerman (of USC) published 2 articles in a 2007 (38:6) issue of Professional Psychology: Research and Practiceon the topic of PTSD in children exposed to family violence.

Article one (pp 613-619) provides an overview. First, they recognize that some kids have PTSD without a single discrete precipitating and/or life-threatening event. It appears that prolonged exposure to violence (e.g., domestic violence, physical abuse, sexual abuse, community violence) likely has a deleterious impact on children. Some 30% of kids living with both parents experience domestic violence. Some 5-10% of kids experience severe physical abuse. One article summarizing a number of studies suggested that somewhere between 13 and 50% of kids exposed to family violence qualify for a PTSD diagnosis. In foster home and clinic studies, the number with PTSD seems higher, especially in girls. Not every child who experiences violence shows signs of PTSD. Severity and frequency of exposure to violence probably matters most. What makes family violence so troubling is that the child is faced with the constant threat of additional episodes.

What are the common domains of impairment related to complex trauma exposure? Affect regulation (inability to modulate anger, chronic flooding of negative affect), information processing (concentration, learning difficulties, missing subtle environmental nuances, overestimation of danger, preoccupied with worry about safety), self-concept (shame, guilt), behavioral control (aggression, proactive defenses, and substance abuse), interpersonal relationships (trust), and biological processes(delayed sensorimotor development (p. 615).

The authors repeat a previous suggestion of a new diagnosis: Developmental Trauma Disorder(DTD) to adequately capture the picture of youth trauma reactions to family violence. Criteria include: repeated exposure to adverse interpersonal trauma, triggered pattern of repeated dysregulation of affect, persistently altered attributions and expectancies about self and other, and evidence of functional impairment.

In their second article (pp. 620-628), the authors summarize typical treatments for children: reexposure interventions(to help the child understand and gain mastery over their past experiences that intrude. This is done primarily by a trauma interview where therapists work directively to bring fragments of the story together into a coherent whole and meaning and safety are explored), cognitive restructuring and education about violence exposure (goal to undo lessons learned, practice thought stopping, and to normalize reactions), emotional recognition and expression (to attend to and understand connections between emotions, thoughts, and behaviors), social problems solving, safety planning for those not able to be out of potentially violent environments, and parenting interventions.

Do any of these treatments work? It appears several do. I’ll mention just one here:Trauma-focused CBT for child abuse victims (by Cohen, Mannarino, and Deblinger. That intervention is published in their 2006 Guilford Press book, Treating trauma and traumatic grief in child and adolescents.   

We should not underestimate the impact of family and community violence on children. There are many kids labeled bi-polar, ADHD, personality disordered, oppositional (and worse) who carry within their body the impact of violence. They might look like a gang-banger or a thug who’d kill you because you scuffed his shoes, but they likely are hypervigilant and only read part of the environmental cues to determine if they are in danger.

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