Youth Athletes Off the Field

outh Athletes Off the Field — School Social Workers Offer Support 
By Liza Greville, MA, LCSW
Social Work Today
Vol. 14 No. 4 P. 22

Sports can be great learning experiences, but student athletes with behavioral health issues may be overlooked in the quest to win.

Will Heininger grew up on the playing field, a fiery, energetic kid who competed in several sports until he settled on football and earned a spot on the roster at the University of Michigan. A standout student with supportive friends and family, he still found himself at a loss after his freshmen year in college when debilitating depression became his toughest opponent. While overcoming this depression, he developed a commitment to education and the hope that others will not suffer in silence.

Today, Heininger works with athletes at the University of Michigan and is a nationally recognized speaker who shares his story of illness and wellness in the hopes of breaking down stigma about mental health issues. In sports cultures where being intense, tough, and stoic often are overvalued, he believes social workers play a valuable role by reaching out to student athletes.

His experience brings to light the struggles that student athletes may hide in order to appear like high-performing adolescents. Given the high rates at which American youths participate in sports, social workers should be aware of the influences, opportunities, and vulnerabilities that such participation may present.

Playing Field
Before exploring ways in which social workers may intervene with student athletes, it is important to emphasize that youth participation in organized sports generally is associated with overall positive outcomes. Gathering data on sports participation is an imperfect science because no central organization regulates all youth sports. However, the Aspen Institute’s Project Play cites a 2012 household survey conducted by Sports Marketing Surveys, which found that of the estimated 51 million U.S. children aged 6 to 17, about 27.4 million play sports in some form or another, casual or organized. This represents more than one-half of American kids.

The Women’s Sport Foundation’s research report Go Out and Play: Youth Sports in America, which is based on two large-scale nationwide surveys, draws the following associations about sports participation: “Sports help create healthy, well-adjusted children. Sports are a health and educational asset for US girls and boys. Organized sports are associated with children’s general health and body esteem, healthy weight, popularity, quality of life and educational achievement” (Sabo & Veliz, 2008, p. 4-5).

“As children participate in sports, they are pulled into networks of peers, coaches, parents, other families, and communities, which increases social capital and reinforces and changes kids’ behavior in positive ways,” explains Don Sabo, PhD, a longtime youth sports researcher; a professor at D’Youville College in Buffalo, NY; and the senior public health advisor for the Women’s Sports Foundation who coauthored this report, about why sports are beneficial from a social capital perspective.

“Some anthropologists who study economically marginalized girls and girls of color have been developing a multiple worlds theory,” he continues. “The gist is that when girls’ involvements criss-cross several different social worlds, they do better developmentally than girls who mainly stay home or are more socially isolated.”

While this theory has not been tested in relation to sports participation, Sabo sees a natural dovetail with social capital theory:

As kids get involved with activity in multiple contexts, their social capital likely will go up, magnifying the positive effects.

Within that positive context, youth athletes nonetheless are vulnerable to a variety of influences unique to competitive environments. Mental health and coping skills, perception of risky and high-risk behaviors, and healthy coaching environments are three areas where social workers can offer intervention.

Talking About Mental Health
Attitudes about relying on personal strength and intrinsic drive are ingrained in athletes from an early age, thus contributing to a stigma about emotional vulnerability and help-seeking. When someone observes almost any youth sports practice field, he or she likely will see shirts emblazoned with slogans such as “Win some, lose none”; “I bust mine to kick yours”; and “Dominate everything.” Also from an early age, youths often are told to toughen up and play through both physical and emotional pain. “There is a tacit assumption not to talk about depression or other emotional issues,” Sabo says.

However, while student athletes may resist coming forward with emotional health issues, professionals in the athletic field do not. There is a surge of interest in student athlete mental health at the collegiate level, as the National Collegiate Athletic Association (NCAA) Mental Health Task Force is scheduled to release an updated NCAA Mental Health Handbook this year.

“One in every four to five young adults has mental health issues,” Timothy Neal, assistant athletic director for sport medicine at Syracuse University, said in a recent ESPN article, “but what is unique about the student-athlete is that they have stressors and expectations of them unlike the other students that could either trigger a psychological concern or exacerbate an existing mental health issue” (Noren, 2014).

While collegiate student athletes face daunting challenges in the transition from high school to college, such as demanding schedules, the distance from home, adjusting to a new level of academics, working with new teammates and coaches, and possibly suffering injuries, they often are underprepared to deal with these stressors because of underdeveloped coping mechanisms.

“The balancing act of being a student athlete is unique,” says Natalie Graves, AM, LCSW, CADC, a private practice social worker in Chicago who specializes in working with high school student athletes. She is not surprised by the focus on mental health disorders in college athletes and sees clear precursors at the high school level. “Student athletes feel the pressure of being constantly observed by parents, teachers, coaches, teammates, and classmates and the pressure to perform at a high level both on and off the field, all while dealing with all the other pressures that come with being a teenager. Student athletes inevitably place expectations on themselves, which in turn creates stress. Often, the only way they know to deal with these pressures is to ignore them and push themselves harder. At some point, that strategy will fail them.”

“There is a sizable group of kids who get the message that they need to be strong and solve their own problems. These are the kids who earn high grades, who are going to college, who are high-performing athletes, and they are the least reporting of their distress,” says Chuck Kron, LMSW, CAS, a school social worker in upstate New York. “These are the kids you’ll see crying in the car after a game. They can be harder to engage because of stigma issues but often will receive help if the school social worker reaches out.”

The University of Michigan’s athletics department employs licensed mental health professionals to work exclusively with student athletes. From a diagnostic perspective, Barb Hansen, LMSW, an athletics counselor, most likely will see students presenting with anxiety, depression, ADHD, and adjustment issues. “Students may not have had much practice coping with frustration and disappointment, and their fear of failure creates heightened anxiety,” she explains. “Often they don’t have adequate self-care skills, and the stigma that talking about emotions is a weakness presents a very real barrier. Normalization of their distress is a key step in engagement.”

Hansen believes that school social workers at the high school level have an opportunity to significantly impact student athletes and their mental health. First, they can reach out to athletic teams and coaches to destigmatize mental health issues and demonstrate that treatment cannot be undervalued. Second, they can make brief outreach efforts to teach relaxation and breathing techniques or mindfulness practices that can greatly benefit students who may eventually confront anxiety issues.

Addressing Perceived Risk and Substance Use
According to a study in the Journal of Adolescent Health, a review of literature suggests that athletes are a high-risk population for alcohol use and sexual activity. The authors noted that while studies of younger athletes indicated that sports participation may serve as a protective factor against behavioral risks, studies of older athletes suggested that sports participation leads to greater behavioral risk (Wetherill & Fromme, 2007, p. 294).

Wetherill and Fromme studied whether perceived risk or perceived likelihood of negative consequences influenced participation in these behaviors. While they did find some gender-specific variations, the overall conclusion was that athletes do drink more frequently, consume more alcohol when they drink, engage in sex with more partners, and engage in unsafe sex more frequently than their nonathlete peers during the last three months of their senior year in high school (p. 298). They found pro-use attitudes developed most strongly in college-bound athletes sometime in high school, and that the increase in drinking begins between 16.5 to 18.4 years of age (p. 299).

While the study did not investigate why this group perceives less risk, possible preferential treatment of athletes or the normative effects of high-risk behaviors among team members may suggest areas for further study.

The findings are useful for social workers engaged in prevention and education work at the high school level. Intervention with student athletes related to violations of interscholastic substance abuse policies is a common role for school social workers and one that is especially valuable given the findings on perceived risk and alcohol use.

Terry Carr, LCSW, LSSW, is a school social worker at a suburban high school in the Milwaukee area where most students go to college, many on athletic scholarships. She cofacilitates a six-week program for students who have violated the athletic code for substance use violations, most often underage drinking. The curriculum is based on the harm reduction model and teaching better decision making skills.

“We challenge the students to reduce substance use and help them to accept the consequences of their actions for themselves and others—their team, their parents,” Carr explains. “We really end up with a lot of discussion once the kids are able to open up about the situations they confront in their social lives.”

Kron facilitates a similar program as part of his responsibilities. “Students are referred to the group for a substance use violation,” he says, “but often underlying problems with depression or anxiety or life at home rise to the surface.”

In addition to the clinical skills required for direct practice with student athletes, Graves sees outreach as a key tool in prevention efforts. “Student athletes are functioning in a closed system, influenced by coaches, trainers, and staff with an objective of accomplishing sports goals,” she says. These environments may have a norming effect on behaviors that put athletes at risk. She makes concerted efforts to develop relationships with coaches, both to facilitate in the referral of students who are struggling and to encourage positive sports environments.

Influencing Coaching Environments
Researchers at the University of Kansas surveyed nearly 400 youths enrolled in a National Youth Sports Program athletic camp and found that “a positive sporting environment can predict their psychological well-being and help them deal with a range of good and bad emotions in life” (KU News Service, 2012).

Mary Fry, PhD, an associate professor of health, sport, and exercise science and the study coauthor, hopes the findings will shift negative coaching behavior: “It is not unusual to see kids who leave sports programs in tears. Coaches are often taught that being hard on their athletes will bring out the best. We know from a great body of research that’s just not the case” (KU News Service 2013).

The authors of a study published online in Pediatrics noted that coaches’ behaviors occur on a continuum from positive to negative, so it can be difficult and somewhat subjective to identify when a coach has crossed the line and to distinguish between an encouraging, affirming environment and a demeaning, shaming one. However, Shields et al. found that negative environments unfortunately are common, as 45% of children in their study reported verbal misconduct by coaches, including name-calling and insulting them during play (as cited in Swigonski, Enneking, & Hendrix, 2014, p. e274).

In addition to the difficulty of differentiating instances of so-called bad behavior from pervasive bullying environments, coaches frequently employ well-honed defensive techniques. Four common defenses are as follows (Swigonski et al., p. e274):

1. Moral justification: A coach will portray the behavior as socially acceptable and time-tested. A coach may say, “This is how we’ve always done things, and we win games” in an attempt to normalize the behavior, excuse responsibility for it, and shift expectations of kids and parents.

2. Backhanded apology: A coach will justify bullying behavior as an appropriate response to inferior performance or poor play. The study authors used this example: “I’m really sorry; I got a little carried away, but we really need to work on fundamentals if we are going to win.” This technique hinges on the coach’s power and the student’s belittlement.

3. Advantageous comparisons: Bullying behavior is compared with more egregious conduct in an effort to minimize humiliation of emotional bullying—for example, “I didn’t touch them. It’s not like I push them around.”

4. Escalation: This technique aims to make a person who may have a grievance back down or give up by suggesting an athlete could quit “if you can’t take or don’t like the way I do things.” The authors clarified that this technique does not necessarily escalate the bullying behavior but instead the consequences of pushing back until the person who has the grievance gives up.

Coaches play make-or-break roles in student athletes’ experiences at any level of competition. The National Council of Youth Sports, a membership-based organization representing more than 200 organizations from Little League baseball to the US Olympic Committee, offers developmentally appropriate online coaching courses, available on the council’s website (www.ncys.org).

The Final Score
Sports are good for kids, except when they are not, and social workers are well-positioned to understand systems issues as well as individual clinical presentations. By drawing on the person-in-environment perspective and understanding common vulnerabilities at both the system and individual levels, social workers can most effectively intervene with student athletes who may or may not appear to be struggling. And educating students, parents, coaches, and communities on positive sports environments and empowering them to insist on standards for healthy environments is an appropriate role for social workers.

— Liza Greville, MA, LCSW, is a therapist in the counseling center at the University of Pittsburgh at Bradford and at Deerfield Behavioral Health, both located in northwestern Pennsylvania.

References
KU News Service. (2012, May 8). Study: Kids in positive sports climate better adjusted, show less depression. Retrieved from http://archive.news.ku.edu/2012/may/8/positive.shtml.

KU News Service. (2013, October 15). Researchers publish article illustrating benefits of sports psychology in youth programs.. Retrieved from https://news.ku.edu/2013/10/07/researchers-publish-article-illustrating-benefits-sport-psychology-youth-programs.

Noren, N. (2014, January 22). Taking notice of hidden injury. Retrieved fromhttp://espn.go.com/espn/otl/story/_/id/10335925/awareness-better-treatment-college-athletes-mental-health-begins-take-shape.

Sabo, D., & Veliz, P. (2008). Go out and play: Youth sports in America. East Meadow, NY: Women’s Sports Foundation.

Swigonski, N. L., Enneking, B. A., & Hendrix, K. S. Bullying behavior by athletic coaches.Pediatrics, 133(2), e273-e275. doi: 10.1542/peds.2013-3146.

Wetherill, R. R., & Fromme, K. (2007). Alcohol use, sexual activity, and perceived risk in high school athletes and non-athletes. Journal of Adolescent Health, 41(3), 294-301.

How Children Grieve

How Children Grieve — Persistent myths may stand in the way of appropriate care and support for children. 
By Kate Jackson
Social Work Today
Vol. 15 No. 2 P. 20

It seems both an obvious and unassailable fact that children will suffer, sometimes acutely, from the loss of important figures in their lives; yet it wasn't long ago that such profound sorrow wasn't widely acknowledged. It wasn't until Freud—not Sigmund, but his daughter Anna—shed light on childhood grief that the subject captured the attention and validation of researchers.

According to Andy McNiel, MA, CEO of the National Alliance for Grieving Children, an organization that encourages awareness of the needs of grieving children and teens and provides resources and education, Freud observed the effects of grief when working with Jewish children orphaned during World War II. Freud's observations, McNiel explains, influenced researchers, most notably John Bowlby, who went on to study how infants were affected by separation from their primary caregivers.

"In recent years," McNiel says, "the debate over whether children actually grieve has been put to rest by such research studies as the pivotal Harvard Child Bereavement Study, conducted by William Worden and Phyllis Silverman." But despite the research, myths and misunderstandings persist, obscuring the needs of children in the wake of a significant loss.

Getting Beyond Misperceptions 
In order to help children cope with loss, both family caregivers and health professionals must recognize the misperceptions that stand in the way of providing children the same understanding and support that is offered adults in mourning.

The Reality of Childhood Grief 
Despite recent research, misperceptions about the very existence of childhood grief persist. According to Mila Ruiz Tecala, LICSW, of the Center for Loss And Grief in Washington, DC, the notion that children are too young to grieve remains prevalent. "That attitude is a disservice to children since it deprives them of the ability to grieve." Research, she says, indicates that a child's core personality is affected by any loss during the early months of life. Losing a primary caretaker, however, especially the mother, "leads inevitably to changes in the daily routine that creates uncertainty and instability in the child's life." Even infants, says Jana DeCristofaro, LCSW, coordinator of children's grief services at The Dougy Center, The National Center for Grieving Children and Families, are affected when a primary caregiver dies. "They will know that the person who is holding them does not smell the same, feel the same, or carry them in the same way."

The Different Faces of Grief 
It's also increasingly clear that not only do children grieve, but they also grieve in different ways or express their grief differently than do adults. "Kids often grieve in spurts because they can't seem to tolerate grief for long periods of time," says Susan Thomas, LCSW-R, FT, program director for the Center for H.O.P.E. at Cohen's Children's Medical Center of New York. Adults, she explains, "have one foot in grief and one foot on the outside, but kids jump in and out of grief." Children may give the appearance of coping well, when suddenly a seemingly innocuous event unrelated to the loss triggers a disproportional response. For example, says Thomas, "A child may scrape her knee and say, 'I wish Daddy were here. If he were here this wouldn't have happened.' Kids are masters at being able to distract themselves and focus on other things, but when something happens, all of the emotion they've been pushing away comes back." This coping mechanism, Thomas says, allows them to "handle the intensity of the experience."

Not only may children and adults grieve in dissimilar ways, but, McNiel says, "Children also grieve in different ways at different ages and stages of life. Their grief might be expressed in an array of emotions such as anger, sadness, fear, and sometimes relief, particularly when there had been long-term illness or perhaps a contentious relationship with the person who died."

It's important to remember, however, DeCristofaro says, that when it comes to grief, those developmental stages are fluid and permeable. "Sometimes you'll see a 3-year-old grappling with something existential as a teenager might."

"Grief does not happen in nice, neat stages, but is unique to the person grieving and influenced by a number of factors in addition to age, including temperament and personality, the relationship they had with the deceased, the relationship they have with the surviving caregiver, the type of death, and the reaction of the adults around them," McNiel says. Grief, he adds, is not very well structured, and all children, like all adults, grieve in their own ways.

Grief May Be Invisible 
Many adults, Thomas says, may believe that if children are not visibly grieving, they're not grieving. "Grief is the internal response and mourning is the external response to loss. Kids may not be showing grief on the outside, but they're grieving tremendously on the inside." When a death occurs, children, like adults, Thomas explains, "go into a shocked, numblike state. It seems as if a shutter comes down in our brain, protecting us from the intensity of the grief experience, and as the weeks and months go on, that shutter slowly goes back up. However, with children, that shutter seems to stay down a bit longer." Children aren't likely to exhibit intense reactions early on, even in the first year. "But that doesn't mean that down the road they may not have some intense reactions," Thomas says.

In addition, grieving is cyclical. "As kids reach new developmental levels, they're going to reintegrate aspects of the grief process using newly acquired processes and skills. Kids will regrieve these important losses at different times in their lives. For example, a girl who loses her mom may have more intense grief reactions at key points in her life such as when she starts to develop physically, when she goes out on her first date, goes to the prom, when she gets married," Thomas says.

It's not always possible for adults to accurately perceive whether or how a child is grieving. Adults may expect to gauge emotion through tears or verbal expression of emotions. And while those may be present, children will behave in different ways and often in a manner that may not outwardly appear to adults to manifest grief.
"Kids will have a wide range of reactions, just as adults do, from sadness to anger to rage to confusion and relief," DeCristofaro says. They may use more than their verbal language to communicate their feelings, she says, also expressing their emotions, for example, through art or play. Adults, she says, must recognize that just because children or teens don't verbalize their feelings, it doesn't mean they are not missing the deceased or feeling sorrow. Depending on the child's age and level of understanding, Tecala agrees, grief may variously be expressed in vastly different ways, in one child by acting out and in another by silence and withdrawal.

As children and teens grapple with what it means to die and struggle to comprehend death's permanence, Thomas says, they may exhibit regressive behaviors such as bedwetting, thumbsucking, separation anxiety, feelings of insecurity, and needing to sleep with parents, especially younger children. "The older they get, the more able they are to understand death and they begin to be able to express their grief more in words, but the younger they are, the more grief comes out in their behavior. Older children may exhibit anger, aggression, or risk-taking behaviors," she adds.

Silence Isn't Golden
Among the reasons children may not verbalize their grief is that they take cues from adults. "They may not feel safe because no one has asked them," DeCristofaro explains. Sometimes, within the family, the child gets signals that talking is wrong or hurtful. They notice or fear that if they bring up the subject they'll create more sadness and more tears.

"Adults might assume that children are better off not thinking about or talking about the person who died. They might remove pictures or avoid talking about the deceased in the presence of children," McNiel says. In response, the children will retreat in silence.

It's not uncommon for children to experience feelings of guilt following a loss (particularly when the deceased is a parent), triggered by the perception they may have somehow contributed to the death. "Because children are ego-centric and view life through a 'magical' lens, they will often feel that they somehow caused the person to die," McNiel says. They may feel that if they'd been better behaved the parent would still be alive, or that there was something they could have done to prevent the death.

This guilt may arise as well if a child had quarreled with the person before the death and concluded, "I wished him dead and it happened," Tecala says. "It's magical thinking, but it can create havoc in a child's psychological well-being."

When those around the child encourage silence and fail to allow the child the freedom to express these feelings, they may persist. They'll need a lot of reassurance, DeCristofaro says, to understand that they didn't influence events and that there was nothing they could have done to prevent a death.

It doesn't help to prevent children from discussing their feelings, but, on the other hand, it's also not helpful, McNiel says, to force children to talk about or express their grief.

Children Can Handle the Truth
Another persistent myth is that the truth is harmful to children or that children are too young to handle the truth about how a person died and about what it means to be dead. "This doesn't protect a child from grief, it only leaves the child to grieve alone," McNiel explains.

Younger children may have little understanding of what death is and what it means. This confusion, says DeCristofaro, "can get compounded by the use of euphemisms such as 'we lost him,' or 'he expired.' The things we say to soften the experience can be very confusing."

Experts agree, the truth is preferable to lying, which fosters mistrust, and clear language can help a child better understand the phenomenon of death and its permanence, as well as the particulars of an individual loss. At the Dougy Center, adults are encouraged to use concrete language when discussing or explaining death to children. "It's painful for adults to share information, and they may be fearful about how the child is going to respond," DeCristofaro says. But children need to understand, when a person dies, "that the person's heart stopped, that he doesn't breathe or sleep anymore, that we won't see him again," DeCristofaro explains.

"Certainly one should consider a child's age in sharing age-appropriate details, and there is no reason to share gruesome details, but whatever is shared with a child should be built upon the truth. When the caregivers in a child's life establish open dialogue about the death, the child often will return with more specific questions as he or she clarifies his or her understanding of what happened. This is true in the case of suicide and homicide as well as other types of death," McNiel says.

Rituals Aren't for Adults Only
It's common for adults to believe that children are too young to attend or even discuss a funeral. "The reality, though, is that children are capable of participating in family rituals," says McNiel, who offers the following caveats:

• Children should not be forced to participate or to talk about the person who died.

• They should be prepared about what they might see or hear when participating and then given the option of whether to participate.

• A plan for an early departure should be put in place in case the child should become overwhelmed and ask to leave.

Grief Abides 
As with adults, grief in children doesn't have a timeline. But while adults may be able to begin to come to terms with loss within a relatively brief time, children, Tecala says, cannot do so until they are in their mid-20s. "It is only at that time that their brains are fully developed that they have the ability to complete the process of reconciling to the death." They not only need to be given the time to cope, Tecala says, without being made to feel baby-ish for having difficulty adjusting to a death but they also need to be supported throughout life stages and when issues resulting from grief reappear.

It's important, DeCristofaro suggests, "to dismantle the terminology of 'getting over something.'" It's a process one goes through, but grief, she adds, doesn't have an end.
"Grief," McNiel agrees, "is not a problem that one needs others to 'fix' or 'solve' or even 'get over.'" It is instead a process that lasts a lifetime, as does one's relationship with the deceased, which rather than ends, transitions over time.

The Tasks of Mourning 
Children and teens may need guidance and support for taking on the tasks of mourning, the most important of which initially is absorbing and adapting to the most basic fact that someone has died and will not be seen again. "After the death of a significant person in their lives, children begin a process of adapting to that person's absence," McNiel says. Grief, he explains, is the normal consequence of acknowledging that their loved one no longer physically exists. "Their relationship with the deceased person moves from one of physical reality to one of memories and continuing bonds."

While there may not be clearly defined stages of grief, there are additional common challenges for children in the aftermath of a death. These tasks, which are highly individual, McNiel explains, were formulated by Worden after he completed the Harvard Child Bereavement Study with his colleague Silverman and have been addressed by other scholars. They include learning to cope with emotions and other changes resulting from loss; developing a new type of relationship or attachment with the deceased based on remembrance; finding meaning from the experience of loss; and reinvesting in life, moving forward, and absorbing the experience into their lives. Even kids, says Thomas, are capable of searching for meaning from the experience of death.

Complications 
The death of a loved one, DeCristofaro says, "is one of the most holistic experiences one will have." Its effects, she says, are cognitive, emotional, spiritual, behavioral, and physical. While many children adjust well and are able to grieve over their losses, some children may have greater challenges.

"Children might struggle with concentrating in school or react in anger, demonstrating an array of problem behaviors," McNiel says. "Often the lack of concentration might be misinterpreted as ADHD or ADD. Children might misbehave at home in ways not typical of their behavior before the death, testing out their new reality," he adds. Many children and teens experience isolation after the death of a loved one and may feel that they stand out from their peers, particularly if no one else among their friends or schoolmates has had a similar experience, DeCristofaro explains. As a result, they may be at greater risk of anxiety and other mental health challenges, substance abuse, and the physical aspects of grief, such as colds, coughs, and stomachaches, she says.

When children are not helped to grieve at every stage of their development, Tecala says, they experience cumulative losses. Among the consequences may be behavior problems such as depression and drug and alcohol use.

How Social Workers Can Help
Not all children will require help adapting to loss beyond that which their family can provide. But in many cases, children will benefit from ongoing support from social workers and other counselors, from support groups, and from peer programs and other grief counseling. Social workers, thus, may be key players who can help children navigate the tasks of mourning and prevent complications that arise from unaddressed grief.

To help facilitate grief, social workers should be alert to issues and behaviors that might suggest that a child is having difficulty coping with a loss, whether or not they are seeing a patient specifically for grief. "I always say one doesn't have to look at it in terms of problems you can diagnose, but rather look at the issues the child is going through now that may be red flags," Tecala says.

Social workers can best assist families by starting with honesty and transparency, DeCristofaro says, "helping children understand who died and how they died, helping parents and adult caregivers feel confident sharing information and fielding questions, and listening—to … ask kids questions and give them choices."

McNiel observes that social workers will need to be patient, "as grief is a lifelong experience for children, and they will come in and out of their grief as they grow and develop into adults." It's helpful, he says, to offer children choices throughout the course of grieving, "from the time of a funeral and when providing support long after the death."

There's no single strategy that will ensure that a child can cope with loss, but a variety of options may be helpful, including art, play, crafts, and memory projects. "Children will move toward those activities that feel most comfortable to them," McNiel says.

Social workers can help, experts agree, by being aware of and avoiding assumptions. "Avoid projecting your own grief onto children and giving advice. Assuming that we know how they feel (even if we had a loss at their age) can highjack their grief, making it more about us than about them," says McNiel, who adds, "Let the child lead you, listen, be present, and follow them in their play."

In the end, Thomas says, children can teach social workers and other adults about their grief experience. "We know a lot as social workers, but everybody's grief experience is different." Listening and allowing children to express themselves in their own way and at their own time is key.

— Kate Jackson is an editor and freelance writer based in Milford, PA, and a frequent contributor to Social Work Today.

RESOURCES 
Social workers and other caregivers can find useful information at the National Alliance for Grieving Children's website (childrengrieve.org) about the needs of grieving kids and teenagers, along with links to numerous resources, including bereavement support programs across the country. Information is also often available from hospice programs, local funeral providers, and children's hospitals, says Andy McNiel, MA, CEO of the National Alliance for Grieving Children.

Other resources include the following:

• The Shared Grief Project (thesharedgriefproject.org);

• The Dougy Center (www.dougy.org); and

• The Centering Corporation (www.centering.org).

— KJ

Fighting Youth Sex Trafficking

March/April 2016 Issue

Fighting Youth Sex Trafficking — The Social Worker's Role
By Christina Reardon, MSW, LSW
Social Work Today
Vol. 16 No. 2 P. 10

The secretive nature of trafficking and a lack of research funding limit understanding of the problem, but social workers can learn to identify and engage victims.

Organizations around the world have partnered with Florida-based Born2Fly on educational programs to prevent youth sex trafficking. But Diana Scimone, Born2Fly's president, struggles to convince school officials in the United States to work with her because many of them don't realize that trafficking is a problem in their communities.

In her role as human trafficking program manager for the Illinois Department of Children and Family Services, Stacy Sloan, MSW, works to raise awareness of youth sex trafficking across the state. But that work is often stymied by the belief that trafficking is only an issue in big cities like Chicago.

Carly Kalish, MSW, RSW, is a social worker serving youths who have been involved in sex trafficking. But she knows her help can only go so far when the public associates trafficking with movies like Taken that portray traffickers as strange men who snatch young people away and force them into sexual slavery in foreign countries.

As these examples illustrate, there are many misperceptions about the nature of youth sex trafficking and, unfortunately, social workers are not immune to these misperceptions. Unless social workers recognize that youth sex trafficking affects youths from all backgrounds in all areas, they may be missing important opportunities to identify victims and help survivors get the help they need.

"Social workers need to realize how important a role they play in all of this," says Eliza Reock, director of programs for Shared Hope International, an antitrafficking organization based in Vancouver, WA. "Social workers are in such a critical place to start identifying these [victims]."

A Knowledge Gap
Under federal law, sex trafficking involves the recruitment, harboring, transportation, provision, or obtaining of a person to perform commercial sex acts induced by force, fraud, or coercion (US Department of Health & Human Services, 2012, August 8). All children under age 18 engaged in commercial sex acts are considered victims of trafficking. A "commercial sex act" does not have to involve an exchange of money but instead anything of value, such as food, shelter, or drugs (US Department of Health & Human Services, 2012, August 2).

It is extremely difficult to identify how many youths are victims of sex trafficking in the United States. A commonly cited figure proposed by Estes and Weiner is that between 244,000 and 325,000 youths are at risk for sex trafficking in the United States (Institute of Medicine and National Research Council, 2013). Research by Davis and Flowers indicates that between 1 and 2 million youths between the ages of 5 and 15 experience domestic sex slavery each year (Countryman-Roswurm & Bolin, 2014).

Accurate prevalence data are hard to come by for several reasons, including a lack of self-disclosure on the part of victims. The secretive nature of trafficking and a lack of funding to research also limit understanding of the true scope of the problem (Countryman-Roswurm & Bolin).

Researchers, advocates, and service providers can't even agree on common terminology. Some sources will refer to "child sex trafficking" or "sex trafficking of minors," while others will refer to "domestic minor sex trafficking," "commercial sexual exploitation of children," or other terms. There also is disagreement about what age a person needs to be considered a victim; some observers say victims must be under 18, while others include young people up to age 22 in their definitions (Countryman-Roswurm & Bolin). (Social Work Today does not endorse one term over another. For simplicity and consistency, the term "youth sex trafficking" is used in this article.)

Perhaps the biggest barrier to clarity about the scope of youth sex trafficking in the United States is that victims are often misidentified or not identified at all by professionals who work with youths. Many social workers aren't prepared to encounter victims because these social workers either don't know the warning signs of trafficking or aren't actively looking for them among the youths they serve.

This knowledge gap is illustrated by a study conducted by researchers at the Medical College of Wisconsin and Children's Hospital of Wisconsin (Beck et al., 2015). The researchers sent a survey to service providers, including social workers, who would be most likely to encounter victims of youth sex trafficking. In two clinical vignettes included in the survey, less than one-half of respondents correctly identified a minor as a trafficking victim (48%) and correctly differentiated a trafficking victim from a child abuse victim (42%).

The results of the survey show how important it is that social workers and other service providers receive training on how to identify victims of youth sex trafficking, says Angela Rabbitt, DO, FAAP, one of the study's authors. The majority of survey respondents (63%) said they had never received such training.

"[Social workers and other service providers] need to be aware of the scope of the problem, who they need to screen, and how to screen," says Rabbitt, an assistant professor of pediatrics at the Medical College of Wisconsin and a youth abuse pediatrician at Children's Hospital of Wisconsin. "Such knowledge is vital because [these providers] are often the first people to have the chance to talk to the youth alone and can identify victims."

Identifying Victims, Engaging Survivors
While each case of youth sex trafficking is different, there are certain warning signs that are common among victims. Risk factors and indicators of youth sex trafficking include the following (Countryman-Roswurm & Bolin; Rabbitt, 2015):
• a history of childhood neglect, abuse, and/or trauma, particularly youth sexual abuse;
• difficult relationships with caregivers;
• family history of substance abuse and criminal activity;
• involvement in abusive or violent dating relationships;
• being homeless and/or a runaway;
• living in a shelter or group home;
• knowing peers or family members who are involved in the sex trade;
• branding/tattoos;
• risky sexual behaviors;
• isolation from peers, friends, and family members; and
• mental health issues such as depression, anxiety, PTSD, ADHD, and chronic stress.

Since social workers may come across many youths with one or more of these risk factors or indicators, it's important that social workers become attuned to subtle clues that may specifically indicate youth sex trafficking, says Kalish, an individual and family therapist at East Metro Youth Services in Toronto, Ontario, Canada. Examples of subtleties a youth may display are having multiple cell phones, going through prominent changes in appearance, having hair and nails done, having expensive items that they don't have the money to afford, withdrawing from usual group of friends or peers, and only spending time with a partner.

Kalish says social workers also must familiarize themselves with the language of the sex trade. Knowing this language will help social workers recognize and comprehend certain words and expressions used by victims, such as "the game," "bottom," "stable," and "daddy." (Shared Hope International has a glossary of common sex trafficking terms at sharedhope.org/the-problem/trafficking-terms.)

"There's a language you have to look for," Kalish says. "If our clients speak French, we better speak French."

Social workers who suspect that a youth has been trafficked should consider their approach carefully. Trafficking victims are unlikely to disclose right away, and confronting them with suspicions could seriously harm the therapeutic alliance. Social workers need to be aware of the strong trauma bonding that often occurs between victims and their traffickers and realize that clinical interventions may not be viewed by victims as helping, Sloan says.

"These kids go kicking and screaming [into services]," she says. "They don't feel that they've been rescued."

Social workers should learn about the mandated reporting laws in their state and be aware that they might be required to call the police and/or child welfare agencies if they suspect trafficking. Social workers are often also advised to call the National Human Trafficking Resource Center hotline at 888-373-7888.

An approach focused on motivational interviewing and stages of change can be an effective way to build trust and rapport with a youth sex trafficking victim, Kalish says. For example, if a victim has no intention to leave the trafficking lifestyle, a social worker can at least work with the victim to ensure that the victim stays as safe as possible. If the victim later is considering leaving the lifestyle, then the social worker can facilitate a process where the victim discusses the pros and cons of trafficking and starts to develop a plan to leave.

The most important thing for social workers to remember is to remain nonjudgmental and to not impose their own beliefs about sex trafficking on the child, Kalish says. "You have to be able to stomach that young people are having sex for money and even though we want them to leave, they may not want to leave," she says.

Social workers must be careful not to assume that treating youth sex trafficking victims is the same as treating child abuse victims, Rabbitt says. For example, putting trafficking victims in group homes for abused and neglected children may not be safe because these facilities might not provide adequate security to deter traffickers intent on trying to coerce the victims back into trafficking.

In addition, social workers must realize that the public perceptions of child abuse victims and youth sex trafficking victims are often completely different, Reock says. While child abuse victims are seen as innocent, youth sex trafficking victims are often made to feel guilty about "choosing" the lifestyle and are labeled as prostitutes. These negative perceptions about youth sex trafficking might make victims less likely to seek help or continue services.

In some cases, the best course of action may be to connect victims to specialized services and programs designed to address the multilayered trauma experienced by trafficking victims, says Erin K. Wirsing, MSW, DELTA program manager at Devereux Florida, an organization serving youths and families. The DELTA program includes a range of services—including residential treatment, individual and group counseling, psychiatric services, nursing care, and foster care—for trafficking victims. Such a variety of services allow Devereux to create an empowerment plan tailored to each victim.

"Youths range in their responses to therapy, and things are going to be very different for each one," Wirsing says. "So we try to be really patient and meet them where they're at."

Getting Involved
Social workers who want to better serve youth victims of sex trafficking must prepare adequately. Services will be more effective and efficient if social workers take time to know what to do before they encounter victims.

Sloan says one good place for social workers to start is to connect with their state or local child welfare agencies to see what information and resources they have to offer. Other resources include the National Center for Missing & Exploited Children, antitrafficking organizations such as Shared Hope International, and federal government websites.

Once social workers learn more about youth sex trafficking, they should consider how to increase their colleagues' awareness of the issue, says Eric Underly, MS, family case management supervisor at Children's Hospital of Wisconsin Community Services. After working with a trafficked youths several years ago, Underly decided to become more knowledgeable about trafficking and now provides guidance to coworkers, has conducted trainings, and presents at conferences.

Another way to build community and professional awareness of youth trafficking is to get involved in multidisciplinary antitrafficking teams and task forces that unite social workers with law enforcement officials, health care providers, representatives of the judiciary, and others. Such teams and task forces ensure that the community's response to youth trafficking is coordinated and covers all aspects of care for victims, from prevention to protection to prosecution, Scimone says.

"It's about getting everyone on the same page and creating a continuum of care," she says. "If people aren't connected and talking to each other, then how can [they] anything get done?"

A proper response to youth sex trafficking requires the social work profession as a whole to do some soul searching about whether it has drifted too far from its social justice roots, says Karen Countryman-Roswurm, PhD, LMSW, executive director of the Center for Combating Human Trafficking at Wichita State University in Kansas. For example, the increasing professionalization of social work has given social workers a level of privilege that can estrange them from youth victims of sex trafficking, many of whom are deeply distrustful of professionals trying to help them.

And social workers partnering on multidisciplinary antitrafficking teams must be careful not to experience role drift and shy away from defending a social justice view of victims. Social workers should not be afraid to stand up for the person-centered, empowerment-based perspective of their profession, Countryman-Roswurm says.

"As a social work profession, it's well past time for social workers to rise up and be very proud of social work," she says. "[Social workers] may be survivors' only advocates. We need to walk alongside them and facilitate a process where they move from a place of pain to holistic prosperity. Rather than being the professional with all of the answers, you need to be willing to put the survivor at the center and they get to be the expert of their own lives."

— Christina Reardon, MSW, LSW, is a freelance writer based in Harrisburg, PA, and a contributing editor at Social Work Today.

References
Beck, M. E., Lineer, M. M., Melzer-Lange, M., Simpson, P., Nugent, M., & Rabbitt, A. (2015). Medical providers' understanding of sex trafficking and their experience with at-risk patients.Pediatrics, 135(4), e895-e902.

Countryman-Roswurm, K., & Bolin, B. L. (2014). Domestic minor sex trafficking: Assessing and reducing risk. Child and Adolescent Social Work Journal, 31(6), 521-538.

Institute of Medicine & National Research Council. (2013). Confronting commercial sexual exploitation and sex trafficking of minors in the United States. Washington, DC: The National Academies Press.

Rabbitt, A. (2015). The medical response to sex trafficking of minors in Wisconsin. WMJ, 114(2), 52-59; quiz 60.

US Department of Health & Human Services. (2012, August 8). Fact sheet: Child victims of human trafficking. Retrieved from http://www.acf.hhs.gov/programs/endtrafficking/resource/fact-sheet-child-victims-of-human-trafficking.

US Department of Health & Human Services. (2012, August 2). Fact sheet: Sex trafficking. Retrieved from http://www.acf.hhs.gov/programs/endtrafficking/resource/fact-sheet-sex-trafficking-english.

[Sidebar]

A COMMON BOND
Emily Forward understands the plight of youth caught up in the world of trafficking because she was once caught up in it, too.

As a peer support worker at East Metro Youth Services in Toronto, Ontario, Canada, Forward taps her lived experience to provide guidance and encouragement to youths involved in trafficking. One way Forward connects to youths is through community outreach presentations aimed at youths in places such as schools, shelters, and transitional living facilities. She helps youths who disclose that they've been trafficked access services. She offers advice to youths about navigating the criminal justice system, coping skills, self-care, and building the resiliency they need to move on with their lives and heal.

Forward's past experience strengthens her rapport with youths and provides a level of comfort that many trafficked youths don't feel with professionals in the behavioral health field. She helps youths see that they are not alone in their struggles. She builds relationships with youths that help them eventually let go of their apprehension and distrust of other services.

"They're much more comfortable talking to people who are a bit younger and have lived experienced so they know what they're going through," Forward says. "It's like talking to a friend and offering whatever support I can to make things for easier for them."

After she left the world of trafficking, Forward began to struggle with her emotional and mental health. A police officer she knew put her in touch with Carly Kalish, MSW, RSW, now an individual and family therapist at East Metro Youth Services. Kalish eventually encouraged Forward to apply to be a peer support worker.

The interactions Forward has with trafficked youths aren't only therapeutic for them; her own healing is encouraged in the process. The interactions have boosted her self-esteem and given purpose to her lived experience. Forward recognizes the value of her experiences as a peer support worker and believes they will help her as she aspires to earn a degree in social work. "I have a very unique specialized knowledge, and I am going to use it to help," she says.

In addition to their direct interaction with youth, Forward and her fellow peer support workers also do presentations for professionals such as police officers, teachers, social workers, and health care providers to help them better understand human trafficking and how to appropriately engage trafficked youths. Her advice to social workers who want to better serve trafficked youths is simple: Keep an open mind and don't expect changes overnight.

"It's really, really important to meet [youth] where they are at," she says. "It might take many, many sessions for them to recognize that they are being exploited. You have to be patient with them; otherwise, they're going to stop coming and think that you don't get it."

— CR

Sex Ed for Young Adults With I/DD

March/April 2016 Issue

Children and Families Forum: Sex Ed for Young Adults With I/DD
By Sue Coyle, MSW
Social Work Today
Vol. 16 No. 2 P. 34

Sex. It's an important part of being human. It's an integral part of romantic intimacy. It's how we develop relationships and build our families. And it's terrifying—at least, it can be.

"How many of us are prepared [for sex]?" asks Aaron McHugh, MS, NCC, QIDP, dual diagnosis specialist for Philadelphia Coordinated Health Care. "How do you assess preparation for sex? Who gave us a test? When it comes down to it, is someone really going to be ready? Who knows? Lots of people have hangups about sex, and their first times were not healthy and happy and pleasurable. So to me, it's the same risk we all take, and I believe every person has the right to have that risk."

Unfortunately, for some individuals, specifically those with intellectual/developmental disabilities (I/DD), the risk is elevated in what may be an attempt to shelter. Too often, young adults with I/DD don't receive the sexual health/sexuality education needed to make safe choices both in regard to sex and their bodies in general.

"Most people with intellectual disabilities are excluded from sex education in school," says Sorah Stein, MA, BCBA, AASECT, a certified sexuality educator. "The problem is that they then lack the information and skills to support socially and age-appropriate sexual behavior."

To Be Human 
There are those who wonder why individuals with I/DD would need sex education, and the answer is easy: they're human. "People with disabilities are wired the same way as everyone else. They have the same core need for meaningful relationships and opportunities to express their sexuality and fulfill sexual needs," explains Leigh Ann Davis, MSSW, MPA, project manager for Justice Initiatives at The Arc.

"Society has traditionally held common misconceptions about people with disabilities," she continues. "They are often seen as having no sexuality at all, or they are seen as being 'oversexed.' The truth is, they are neither, though their surroundings and environments can have a lot to do with how and why they are given these labels. First of all, people with I/DD are sexual beings and have sexual needs and desires just like all people. Their intellectual functioning does not preclude them from having sexual feelings for others, wanting close relationships, wanting to get married, or having a family."

Melissa Keynes DiMaggio, CASE, co founder and director of education of Finding Your Individuality, agrees, adding that having basic sexual health knowledge enables all individuals to feel even more human. "One of the reasons why I believe this work is so important is because it's life affirming. It's a really important thing to know how your body works. Our folks [individuals with I/DD] often struggle with transformations. It may be less overwhelming for that young person if they get the information they need to take care of their bodies."

To Be Safe
Beyond the basic right of being human and being sexual is the understanding that more information—more sex education—would enable individuals with I/DD to be safer and more prepared for sexual encounters, something that is very much needed.

"People with ID are more likely to be sexually victimized," McHugh says. "They're definitely less likely to report, and they're more likely to suffer more long-term consequences."

Davis adds, "It is well documented just how often sexual violence occurs in the lives of people with intellectual and/or developmental disabilities. Research suggests percentages as high as 80% of women who have I/DD and 50% of men with I/DD will be sexually abused before the age of 18," she says. "It is important that we teach skills that make it less likely for people with ID to be victimized, and also more likely to report it if it does occur."

In young adults and adults with I/DD who are able to consent to sexual activity, a lack of education can lead to dramatization. McHugh recalls a young woman who decided along with her boyfriend to have sex. He also had a disability.

"She didn't know what sex was," McHugh says. "[The boyfriend] wanted anal sex, and he violated her anally. She was traumatized by it. She hadn't received any sex education.

"It's better to educate so that individuals with I/DD are aware of what can potentially happen than just turning a blind eye to it and assuming it will never happen."

When to Start
But when should such education start? Sex education typically begins in the school system for youth in or around the age of puberty. Middle school and high school have been deemed the appropriate times developmentally for teachers and parents to broach the subject. However, young adults with I/DD aren't on the same levels developmentally. So should there be a delay?

Short answer: No.

"I do not believe that people should wait to present sex education based on ages, particularly when kids in their cohort who are non disabled are receiving their education," McHugh says.

Longer answer: Even puberty is too late.

"We are sexual beings from birth until death," DiMaggio says. "Sexual education happens when a person is born into this world. Having early interactions with a child—naming body parts, communicating boundaries—is critical. Talk early, talk often, talk all the time," she says, referencing a motto of Sexuality Information and Education Council of the United States (SI ECUS).

Doing so will enable the individuals to be more aware should they be victimized. "If we define sex education more broadly, education needs to start very early by teaching young children with I/DD correct terms about their body parts so that if sexual abuse occurs, they will be able to talk about it clearly," Davis says.

It will also enable individuals to know what is and is not appropriate, so as to avoid miscommunication and mislabeling. McHugh again recalls a client who had a rash near his groin. "He was tugging at his penis [to relieve the itch]," he says, "and the whole team wanted a sexuality consultant when he actually needed medical treatment."

"When I hear that story, I identify with that story," DiMaggio follows. "People with I/DD are individuals that need sexual education the most and are punished the most for not receiving it."

Where to Start 
While young people with I/DD should be treated as any other individual when it comes to the theory of sexual education and its delivery, the actual practice of teaching does require specialized thought.

"Important things to keep in mind when providing education is to make sure the information is given in a format that makes it easy for the child/youth to understand," Davis says. "They are very much concrete thinkers and need information provided in simple-to-follow ways. It's important to individualize the information whenever possible, so that it gives the lesson being taught more context that relates to his or her world. For example, if a youth with autism is fixated with a certain topic, use that to help the youth connect to what is being taught."

McHugh recommends visuals. "The more visuals the better. I would say to look for any kind of charts on anatomy, as well as real-life scenarios and have the anatomical parts. Have dolls with the actual anatomical parts." He also strongly encourages the use of available resources. "I have to say, regardless of what other people's opinions may be, one of the greatest resources is Planned Parenthood."

DiGioia advises doing some research beforehand, recommending several books written on the subject. "There are a couple of books that come to mind for me, particularly for parents or professionals working with their young people," she says. "Terri Couwehnhoven wrote Teaching Children with Down Syndrome about Their Bodies, Boundaries, and Sexuality: A Guide for Parents and Professionals. It is really fantastic. It gives a framework for why to teach and gives some guidance on how to do it."

Other books include Sexuality: Your Sons and Daughters with Intellectual Disabilities by Karin Melberg Schwier and David Hingsburger and The Facts of Life … and More: Sexuality Education for People with Intellectual Disabilities by Leslie Walker-Hirsch.

For a more complete list of available books, DiGioia recommends visiting the SIECUS website (www.siecus.org).

As for a specific curriculum, that may be more difficult. "Because of the wide range of learning impairments associated with intellectual disability, it is difficult to create or modify curricula in a way that can be globally used," Stein says. "Much time and effort, not to mention knowledge, is required to identify what each learner needs, where to access the information and how to present it to facilitate successful and lasting learning."

McHugh agrees. "There are not a lot of I/DD-specific things," he says. "People have tried to create curriculum specific to people with different disabilities. But I don't know any top-notch ones. It comes down to the instructor. It comes down to the clinician."

But it doesn't just come down to any one individual, whether an instructor, clinician, or parent. Rather, it's about the team of individuals working together to provide the best information.

As DiMaggio puts it, "Sex education doesn't happen in a bubble."

— Sue Coyle, MSW, is a freelance writer and social worker in the Philadelphia area.

Resources
National Center on Criminal Justice and Disability. (2015). Violence, abuse and bullying affecting people with intellectual/developmental disabilities: A call to action for the criminal justice community. http://www.thearc.org/document.doc?id=5145.

Motivational Interviewing and Addictions: Collaboration, Not Confrontation

November/December 2015 Issue

Motivational Interviewing and Addictions: Collaboration, Not Confrontation
By Christina Reardon, MSW, LSW
Social Work Today
Vol. 15 No. 6 P. 22

Though it has its critics, motivational interviewing has proven effective with clients capable of engaging with clinicians who operate from a strengths-based perspective, tapping into internal wisdom and resources, rather than viewing the client as someone with deficits that need to be "fixed."

Ambivalence about change is part of the human experience. You want to exercise more, but you'd rather watch your favorite TV show than go to the gym. You want to lose weight, but the sweets displayed in the window of the neighborhood bakery look so good.

Substance abusers face ambivalence, too. On one hand, they see how addiction has damaged their health, their families, their careers. On the other hand, they don't want to give up that pill, that drink, that high.

Many clinicians trying to help clients resolve this ambivalence turn to advice giving in an effort to persuade the user to give up drugs or alcohol. These helpers are often surprised when their efforts backfire, and the client continues to use.

Motivational interviewing (MI) provides an alternative to this destructive cycle of confrontation and resistance. MI is built on the premise that the clinician is not there to force clients to change but instead should facilitate the capacity clients already have within themselves to change. Although now used in fields as diverse as health care, education, and criminal justice, MI's roots are in addiction, and clinicians working with substance abusers from all walks of life are increasingly using the approach.

"[MI] gets clients thinking on a different level because they're the ones making the decisions," says Daryl Cioffi, MEd, CAGS, LMHC, co-owner of Polaris Counseling & Consulting in Rhode Island. "You get people to tap into their own power. You're just there to help them along the way."

MI: An Overview
William R. Miller, PhD, a professor of psychology and psychiatry at the University of New Mexico, originally outlined MI in the early 1980s. Miller and psychologist Stephen Rollnick, PhD, have further developed and refined the concepts of MI in subsequent editions of their book,Motivational Interviewing: Helping People Change (2013).

MI is not a therapy itself, but a conversational style or way of being that a clinician uses when interacting with clients. The approach is focused on conversations around change, primarily those involving ambivalence when clients are going back and forth about making changes.

Underpinning MI is the idea that people tend to rebel when they feel that they are being forced to choose a certain course of action in resolving ambivalence. Unfortunately, this urge to pressure people to make the "right" decision about change—what Miller and Rollnick call the "righting reflex"—is prevalent among many well-intentioned helpers, including those working in professional settings.

Miller and Rollnick argue that people are more likely to change when hearing themselves speak about the reasons to change and how that change might be accomplished. MI is designed to gently guide clients toward focusing on that change talk—statements that promote change—and away from sustain talk—statements that promote the status quo. Clinicians create an environment that fosters change talk by embodying Miller and Rollnick's "spirit of MI," which includes the following elements:

• Partnership: The clinician and client collaborate in the journey toward change. The clinician's role is to listen to and support the client, not to tell the client what to do.

• Acceptance: The clinician accepts what the client brings to the partnership. This acceptance involves respecting the client's inherent worth, practicing empathy with the client, supporting the client's autonomy, and affirming the client's strengths.

• Compassion: The clinician commits to promoting the client's welfare and best interests.

• Evocation: The clinician operates from a strengths-based perspective and helps the client tap into internal wisdom and resources instead of seeing the client as someone with deficits that need to be "fixed."

Practicing in the spirit of MI involves more than an intellectual belief that these elements are important for a good therapeutic relationship. Clinicians must put these elements into action during interactions with clients, says Paul Burke, MA, RSW, team leader at Paul Burke Training & Consulting Group, which provides MI training throughout Canada. "It's a set of interviewing habits you have to get into," he says.

In addition to the four elements of the spirit of MI, the following four processes that emerge in MI (Miller & Rollnick): engagement (building rapport, developing a therapeutic alliance); focusing (seeking clarity in the direction of the change discussion and change goals); evoking (guiding clients to voice arguments that support change); and planning (committing to change and discussing how to pursue change). Each process builds the foundation for subsequent processes. The five key communication skills used by clinicians during these processes are asking open-ended questions, affirming, reflecting, summarizing, and providing information and advice with permission (Miller & Rollnick).

MI and Addiction
Miller began to develop MI after beginning to question the confrontational style of addiction treatment that was in vogue during the late 20th century. Using the confrontational style, clinicians would yell at, argue with, denounce, humiliate, and otherwise verbally abuse clients in an effort to break through their denial (White & Miller, 2007).

Miller observed that confrontation tended to lead to a vicious cycle (Miller & Rollnick). The confrontation made clients defensive. Clinicians interpreted this defensiveness as resistance, which convinced them that they had to confront even more. MI offered a new way to approach clients in a much more collaborative, nonjudgmental way.

MI has been used in a variety of interventions addressing issues such as alcoholism, heavy drinking, drinking and driving, smoking, marijuana use, and cocaine use. Evidence suggests that MI can be useful in helping people change problematic behaviors related to substance use and abuse. Studies that point to MI as a promising practice in the addictions field include the following:

• A review of four meta-analyses by Lundahl and Burke (2009) found that MI was significantly more effective than no treatment and generally as effective as other approaches for treating substance abuse to increasing client engagement in treatment.

• Smokers in Spain who were randomly assigned to MI were more likely to have remained abstinent from smoking after six and 12 months than those assigned to an intervention where they received antismoking advice (Soria, Legido, Escolano, Yeste, & Montoya, 2006). The authors surmised that participants in the group receiving advice might have perceived such advice as preaching and thus engaged in contrarian behavior.

• A study of 423 substance users entering outpatient treatment in five community-based settings in Oregon, Virginia, and New York showed better treatment retention rates for clients randomly assigned an intake that integrated MI techniques vs. a standard intake. The MI-adapted intake, however, did not lead to any difference in substance-use outcomes at 28-day or 84-day follow-ups (Carroll et al., 2006).

• Problem drinkers randomly assigned to directive-confrontational counseling showed significantly more resistance than those assigned to client-centered counseling. The resistance predicted poorer outcomes at 12-month follow up (Miller, Benefield, & Tonigan, 1993).

Both MI and motivational enhancement therapy (an adaptation of MI) appear on the Substance Abuse and Mental Health Services Administration's National Registry of Evidence-based Programs and Practices (NREPP). Information about additional research on these interventions can be found on NREPP's website (www.nrepp.samhsa.gov).

MI is especially useful in working with clients struggling with addiction because these clients tend to be incredibly ambivalent about their substance use, says James M. Walsh, PhD, LPCMH, BACC, a pastoral counselor in Delaware and a former program assistant in the MS in Clinical Mental Health Counseling program at Wilmington University. Walsh says MI also can be used to help clients move to a place where they are willing to explore painful experiences or situations that have contributed to their substance abuse.

MI is not intended to replace other therapeutic approaches, such as cognitive behavioral therapy, but instead can be used as a tool within other approaches to resolve ambivalence whenever it arises. "The integration of [MI] into my practice is seamless," Walsh says. "It's something that I may work on with a person a minute here and there, or it may take up most of a session."

Burke first learned about MI in 1993 when he was in the addictions field and attended a training conducted by Rollnick, MI's codeveloper. Burke says he was immediately struck at how nonconfrontational and respectful the approach was—leading to a much more positive and engaging experience for clients.

Maryellen Evers, LCSW, CAADC, who has a private practice at Ronald J. Refice & Associates in Pennsylvania, has noticed that MI works particularly well in helping her forge therapeutic alliances with adolescent clients. Adolescents who come into therapy expecting to be lectured like they have by their parents or other adult authority figures are pleasantly surprised when they are trusted to make their own decisions. In addition, Evers says, MI engages clients who are not ready for complete abstinence from substances because by putting clients in control of their decisions, MI leaves open harm reduction or moderation as options.

Perhaps the most surprising thing about MI is not the impact it has on clients struggling with substance use but the impact it has on clinicians. Behavioral health professionals discussing MI repeatedly use words like "enjoyable," "energized," "easy," and "enthusiastic" to describe their experiences practicing MI.

MI releases the clinician from having to struggle with clients to get them to make changes in their lives, says Brian Hurley, MD, MBA, an addiction psychiatrist and Robert Wood Johnson Foundation clinical scholar at UCLA. "I found MI to be transformative in my practice. It's made my practice fun because I am working with patients on goals they define rather than those I define."

These benefits do not have to be limited to clinicians. At Hazelden Betty Ford Foundation's facilities in the Tribeca and Chelsea neighborhoods of New York City, even nonclinical staff receives training about MI so the approach is infused into all the services clients encounter. "[MI] is used from the start, from the moment that someone participates in an assessment," says Barbara Kistenmacher, PhD, executive director of Hazelden Betty Ford Foundation's New York campus. "It's woven into everything we do."

Easier Said Than Done 
Despite its many benefits, MI is not a panacea. There are certain situations in which its use with substance users may be ineffective or even counterproductive, says Amber Madden, MA, LPCA, of Madden Wellness Counseling in Kentucky. For example, Madden says MI might not be initially appropriate with clients in crisis because these clients need to resolve the crisis first before engaging in conversations about change.

Another red flag with MI is if clients are already committed to change and confident about making it, says Sarah A. Suzuki, LCSW, CADC, of Chicago Compass Counseling. In that case, discussing ambivalence may stymie clients' progress.

MI has acquired a certain cachet as it has become more well-known and popular, with more and more behavioral health professionals claiming that they practice MI or in the MI style. But many of these practitioners—both in addictions and in other fields—have misconceptions about MI. One of these misperceptions, Burke says, is that MI is the same as motivational speaking—a kind of pep talk that gets people pumped up and enthusiastic.

Another misperception centers on how MI can be learned. Miller and Rollnick, for example, express their dismay about some clinicians' perceptions of MI as being a simple set of verbal tricks that can be taught to staff during the lunch hour. In fact, it takes a lot of time and hard work to master the approach, Cioffi says. "You're not just going to be able to watch a YouTube video and learn it," she says.

Cioffi and several other addiction treatment professionals offered the following advice to clinicians who want to become proficient in MI:

• Learn about MI. Reading about MI, looking at articles, and watching videos are among the many activities addictions professionals can engage in to learn about the method of MI and the concepts behind it.

• Learn how to do MI. Taking the leap from knowing MI to doing it requires intensive training, preferably training that includes role plays, teach-backs, and other opportunities to demonstrate MI skills. The Motivational Interviewing Network of Trainers is a good way to find out about upcoming trainings (www.motivationalinterviewing.org). Try to bring at least one other person with you to trainings so you can continue to practice together and provide feedback to one another once the training is over.

• Do MI. Practicing MI is key to becoming skilled at it. Get clinical supervision from someone who is well-experienced in MI. Record your sessions and use a coding tool to assess the quality of and the fidelity to the MI approach.

Practicing MI is essential to getting to a point where MI comes naturally when interacting with clients, Suzuki says. She likens the process to learning how to play the piano. Listening to music and reading books about the piano are only going to get you so far; it takes practice to truly become prepared to perform.

Mastering MI may be harder than some clinicians think it will be because practicing the radical acceptance MI requires is difficult, and it can be easy to slide back into directing, advice-giving behavior, Walsh says. It may be especially challenging for clinicians working in addictions, Hurley adds, because of addiction treatment's long history of confrontation. "Sometimes people have a fair amount of unlearning to do of well-worn patterns that are not compatible with [MI]," Hurley says.

Just as MI practitioners must practice patience with and acceptance of their clients, they also must be patient with and accepting of themselves as they try to use MI, Suzuki says. "It's OK to make mistakes; even the most experienced practitioners aren't perfect," she says. "The only way I can do it is to keep practicing. It becomes more fun and easier and more fulfilling the more you do it."

— Christina Reardon, MSW, LSW, is a freelance writer based in Harrisburg, PA, and a contributing editor at Social Work Today.

References
Carroll, K.M., Ball, S.A., Nich, C., Martino, S., Frankforter, T.L., Farentinos, C., et al. (2006). Motivational interviewing to improve treatment engagement and outcome in individuals seeking treatment for substance abuse: A multisite effectiveness study. Drug and Alcohol Dependence, 81(3), 301-312.

Lundahl, B., & Burke, B.L. (2009). The effectiveness and applicability of motivational interviewing: A practice-friendly review of four meta-analyses. Journal of Clinical Psychology, 65(11), 1232-1245.

Miller, W.R., Benefield, R.G., & Tonigan, J.S. (1993). Enhancing motivation for change in problem drinking: A controlled comparison of two therapist styles. Journal of Consulting and Clinical Psychology, 6(3), 455-461.

Miller, W.R., & Rollnick, S. (2013). Motivational interviewing: Helping people change. 3rd ed. New York, NY: The Guilford Press.

Soria, R., Legido, A., Escolano, C., Yeste, A.L., & Montoya, J. (2006). A randomised controlled trial of motivational interviewing for smoking cessation. British Journal of General Practice, 56(531), 768-774.

White, W.L., & Miller, W.R. (2007). The use of confrontation in addiction treatment: History, science and time for change. Counselor, 8(4), 12-13.