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My name is Mark Durgee and I am currently enrolled in the Master of Arts (M.A.) in Mental Health and Wellness Counseling program with an expected graduation of 2024. I plan to provide counseling services remotely, in English from my home in Merida, Mexico. I am excited to work for myself and not as a contributor.

I feel this course is a good primer into the topic of crisis, traumas, and mental health. I look forward to picking up key concepts, tools, techniques, and resources in this course to begin my journey. You have to start somewhere.

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My learning goal for this course is to connect my existing knowledge of the topic with new theories, communities, and applications that can make me a more effective practitioner.

My biggest takeaway from reading this module's materials, visiting links, and taking quizzes is that I didn’t realize the true impact of mental health on communities, what communities are most impacted, and who gets help. I was surprised about a few things. Depression is the leading cause of disability worldwide. I had no idea. Serious mental illness costs the US over $190 billion a year. That is mind-blowing. I am also surprised that the population with the highest rates of mental illness identifies as being two or more races. I want to search for studies that can tell me more about this.

I have experienced mental health conditions in my life and experienced various levels and varieties of treatment. I am interested in exploring and reflecting on these experiences through the course to make more meaningful connections.

I am looking to use the experiences in this course to more easily connect with future clients.  I plan to use experiences from this course and develop practices that focus on destigmatizing mental illness and those who seek support after trauma or a crisis. Even as someone who has received treatment for mental health treatment, I know I have a lot to learn.

One process that I am eager to incorporate into my discussions through this course is narrative counseling. I believe that we are experts in our own lives and sometimes need help telling stories that separate us from the problems we experience in a respectful, non-blaming way. The Dulwich Centre is a great resource for more information on this topic.

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Introduction

There are many different themes which make up what has come to be known as 'narrative therapy' and every therapist engages with these ideas somewhat differently. When you hear someone refer to 'narrative therapy' they might be referring to particular ways of understanding people's identities. Alternatively, they might be referring to certain ways of understanding problems and their effects on people's lives. They might also be speaking about particular ways of talking with people about their lives and problems they may be experiencing, or particular ways of understanding therapeutic relationships and the ethics or politics of therapy.

Narrative therapy seeks to be a respectful, non-blaming approach to counselling and community work, which centres people as the experts in their own lives. It views problems as separate from people and assumes people have many skills, competencies, beliefs, values, commitments and abilities that will assist them to reduce the influence of problems in their lives.

There are various principles which inform narrative ways of working, but in my opinion, two are particularly significant: always maintaining a stance of curiosity, and always asking questions to which you genuinely do not know the answers. I invite you to read this book with these two principles in mind. They inform the ideas, the stance, the tone, the values, the commitments and the beliefs of narrative therapy.

Possibilities for conversations

When I meet with the people consulting me, I sometimes think of the possibilities for the directions of the conversation as if they are roads on a journey. There are many cross-roads, intersections, paths and tracks to choose from. With every step, a new and different cross road or intersection emerges - forwards, back, right, left, diagonal, in differing degrees. With each step that I take with the person consulting me, we are opening more possible directions. We can choose where to go and what to leave behind. We can always take a different path, retrace our steps, go back, repeat a track, or stay on the same road for some time. At the beginning of the journey we are not sure where it will end, nor what will be discovered.

The possibilities described in this book are like the roads, tracks and paths of the journey. Each question a narrative therapist asks is a step in a journey. All the paths may be taken, some of the paths, or one can travel along one path for a time before changing to another. There is no 'right' way to go - merely many possible directions to choose from.

Collaboration

Importantly, the person consulting the therapist plays a significant part in mapping the direction of the journey. Narrative conversations are interactive and always in collaboration with the people consulting the therapist. The therapist seeks to understand what is of interest to the people consulting them and how the journey is suiting their preferences. You will often hear, for example, a narrative therapist asking:

How is this conversation going for you?

Should we keep talking about this or would you be more interested in ...?

Is this interesting to you? Is this what we should spend our time talking about?

I was wondering if you would be more interested in me asking you some more about this or whether we should focus on X, Y or Z? [X, Y, Z being other options]

In this way, narrative conversations are guided and directed by the interests of those who are consulting the therapist.

Summary

So, before we dive into this exploration of narrative ways of working, let's quickly summarise what we have considered so far:

Narrative therapy seeks to be a respectful, non-blaming approach to counselling and community work, which centres people as the experts in their own lives.

It views problems as separate from people and assumes people have many skills, competencies, beliefs, values, commitments and abilities that will assist them to change their relationship with problems in their lives.

Curiosity and a willingness to ask questions to which we genuinely don't know the answers are important principles of this work.

There are many possible directions that any conversation can take (there is no single correct direction).

The person consulting the therapist plays a significant part in determining the directions that are taken.

It seems appropriate to begin any exploration of narrative therapy with a consideration of what is meant by the 'narratives' or 'stories' of our lives.

Chapter 1: Understanding and living our lives through stories

Narrative therapy is sometimes known as involving 're-authoring' or 're-storying' conversations. As these descriptions suggest, stories are central to an understanding of narrative ways of working.

The word 'story' has different associations and understandings for different people. For narrative therapists, stories consist of:

As humans, we are interpreting beings. We all have daily experiences of events that we seek to make meaningful. The stories we have about our lives are created through linking certain events together in a particular sequence across a time period, and finding a way of explaining or making sense of them. This meaning forms the plot of the story. We give meanings to our experiences constantly as we live our lives. A narrative is like a thread that weaves the events together, forming a story.

We all have many stories about our lives and relationships, occurring simultaneously. For example, we have stories about ourselves, our abilities, our struggles, our competencies, our actions, our desires, our relationships, our work, our interests, our conquests, our achievements, our failures. The way we have developed these stories is determined by how we have linked certain events together in a sequence and by the meaning we have attributed to them.

An example: the story of my driving

I could have a story about myself as a 'good driver'. This means I could string together a number of events that have happened to me whilst driving my car. I could put these events together with others into a particular sequence and interpret them as a demonstration of me being a good driver. I might think about, and select out for the telling of the story, events such as stopping at the traffic lights, giving way to pedestrians, obeying the speed limits, incurring no fines and keeping a safe distance behind other vehicles. To form this story about my ability as a driver, I am selecting out certain events as important that fit with this particular plot. In doing so, these events are privileged over others.

As more and more events are selected and gathered into the dominant plot, the story gains richness and thickness. As it gains thickness, other events of my driving competence are easily remembered and added to the story. Throughout this process, the story thickens, becomes more dominant in my life and it is increasingly easy for me to find more examples of events that fit with the meaning I have reached.

These events of driving competence that I am remembering and selecting out are elevated in their significance over other events that do not fit with the plot of being a good driver. For instance, the times when I pulled out too quickly from the curb or misjudged the distances when parking my car are not being privileged. They might be seen as insignificant or maybe a fluke in the light of the dominant plot (a story of driving competence). In the retelling of stories, there are always events that are not selected, based upon whether or not they fit with the dominant plots.

The diagram on the next page [this figure cannot be represented here on this webpage but is included in the book!] demonstrates the idea of stories consisting of events linked in sequence across time according to plot. The X marks are all the events that have occurred in my life as a driver. The events that fit with the story of 'driving competence' are scattered amongst events that are outside of that story (e.g. a car accident that occurred 4 months ago). In order to author a story of driving competence, certain events are selected out and privileged over other events. Once privileged, they are linked with other events, and then still more events across time, to form a story about being a good driver. The line on the diagram shows this linking of events to form the dominant story. As you can see there are other events (X) that are outside of this dominant story that remain hidden or less significant in the light of the dominant plot.

In this example, perhaps why I can attend only to the good events, and have managed to construct a story of being a competent driver, is due to the reflections of others. If my family members and friends have always described me as a good driver, this would have made a significant difference. Stories are never produced in isolation from the broader world. Perhaps, in this example, I was never subjected to diminishing remarks on the basis of my gender. Who knows?

The effects of dominant stories

The dominant story of my driving abilities will not only affect me in the present but will also have implications for my future actions. For example, if I am asked to drive to a new suburb or drive a long distance at night, my decision and plans will be influenced by the dominant story I have about my driving. I would probably be more inclined to consider doing these things when influenced by the story I have about myself as being a good driver than if I had a story about myself as being a dangerous or accident-prone driver. Therefore, the meanings I give to these events are not neutral in their effects on my life - they will constitute and shape my life in the future. All stories are constitutive of life and shape our lives.

Living many stories at once

Our lives are multistoried. There are many stories occurring at the same time and different stories can be told about the same events. No single story can be free of ambiguity or contradiction and no single story can encapsulate or handle all the contingencies of life.

If I had a car accident, or if someone in my life began to focus on every little mistake that I ever made while driving, or if a new law was introduced that discriminated against people like me in some way, an alternative story about my driving might begin to develop. Other events, other people's interpretations of these events, and my own interpretations could lead to an alternative story developing about my driving - a story of incompetence or carelessness. This alternative story would have effects too. For a time I might live with differing stories about my driving depending upon the context or the audience. Over time, depending on a variety of factors, the negative story about my driving might gain in influence and even become the dominant story in my life in relation to my driving. Neither the story of my driving ability nor the story of my driving failure would be free of ambiguity or contradiction.

Different types of stories

There are many different sorts of stories by which we live our lives and relationships - including stories about the past, present and future. Stories can also belong to individuals and/or communities. There can be family stories and relationship stories.

An individual may have a story about themselves as being successful and competent. Alternatively they may have a story about themselves as being 'a failure at trying new things' or 'a coward' or as 'lacking determination'. Families may have stories about themselves as being 'caring' or 'noisy' or 'risky' or 'dysfunctional' or 'close'. A community may have a story about itself as 'isolated' or 'politically active' or 'financially strong'. All these stories could be occurring at the same time, and events, as they occur, will be interpreted according to the meaning (plot) that is dominant at that time. In this way, the act of living requires that we are engaged in the mediation between the dominant stories and the alternative stories of our lives. We are always negotiating and interpreting our experiences.

The broader social context of the stories by which we live our lives

The ways in which we understand our lives are influenced by the broader stories of the culture in which we live. Some of the stories we have about our lives will have positive effects and some will have negative effects on life in the past, present and future. Laura may describe herself as a skilled therapist. She has developed this story about herself from her experiences and feedback from her work. All these experiences have contributed to shaping a story about herself as a competent, caring and skilful therapist. When faced with the decision to apply for a new job in a field that is less familiar to her, Laura is more likely to apply or think about applying under the influence of this positive self-narrative. I suspect that she would experience the challenges in her work with some confidence and might talk about her work in ways that describe it as enriching.

The meanings that we give to these events occurring in a sequence across time do not occur in a vacuum. There is always a context in which the stories of our lives are formed. This context contributes to the interpretations and meanings that we give to events. The context of gender, class, race, culture and sexual identity are powerful contributors to the plot of the stories by which we live. Laura's story of herself as a skilled therapist, for instance, would have been influenced by the ideas of the culture in which she lives. This culture would have particular beliefs about what constitutes 'skills' as a therapist and Laura's story would be shaped by these beliefs.

Laura's working-class background may have significantly contributed to the ways in which she finds it easy to make connections with people who come to consult with her from a diversity of backgrounds. Her confidence in speaking out in work situations may have much to do with her history within the feminist movement and also the fact that as she is a white Australian professional, it is likely that people will listen to what she is saying.

In these sorts of ways, the beliefs, ideas and practices of the culture in which we live play a large part in the meanings we make of our lives.

Summary

As I have tried to explain, narrative therapists think in terms of stories - dominant stories and alternative stories; dominant plots and alternative plots; events being linked together over time that have implications for past, present and future actions; stories that are powerfully shaping of lives. Narrative therapists are interested in joining with people to explore the stories they have about their lives and relationships, their effects, their meanings and the context in which they have been formed and authored.

Chapter 2: Stories in the therapeutic context

Let us think about some of the stories that are brought into the context of therapy. Most commonly, when people decide to consult a therapist it is because they are experiencing a difficulty or problem in their lives. When meeting with a therapist, they will often begin by telling the therapist about many events in the life of the problem for which they are seeking help. Commonly they will also explain the meanings they have given to these events.

The Craxton family sought my assistance when one of the members of the family, Sean, was caught stealing. As I heard about the problem of stealing, Sean's parents explained:

We are really worried about Sean because he is stealing and we have tried to stop him but he just won't. He's always been a problem child from the time he was little. He didn't get much attention when he was a small boy because Anne [his mother] was ill. Since then he always gets in trouble at school. He didn't toilet train himself and is always starting fights with his brothers. Now he's stealing to get people to notice him.

Within this story, Sean's stealing was interpreted as meaning he was 'attention seeking'. This particular meaning (or dominant plot) occurred through a gathering together of many other events in the past that fitted with this interpretation. As Sean more and more came to be seen according to this story, more and more events which supported the story of 'attention seeking' began to be selected out, and the story was told and re-told. As more events were added to this plot, the story of Sean as an 'attention seeker' became stronger.

To tell this particular story, certain events from the present and past were selected out and explained to fit with the meanings that his parents had arrived at. In doing so, certain events were selected and privileged to be told, as they were interpreted to fit with the plot of 'attention seeking'. Therefore, other events (that didn't fit with Sean as seeking attention) remained untold and unrecognised. The exceptions to this story of 'attention seeking' or times that might not fit with the 'attention seeking' story became less visible. So too, the broader cultural understandings of Sean's actions become obscured - including the fact that stealing is a common act by young men of Sean's class background in his neighbourhood. All the complexities and contradictions of Sean's life had been simplified into the understanding that Sean was an 'attention seeker'.

Thin description

Early in their meetings with people, therapists often hear stories, like the one above, about the problem and the meanings that have been reached about them. These meanings, reached in the face of adversity, often consist of what narrative therapists call 'thin description'.

Thin description allows little space for the complexities and contradictions of life. It allows little space for people to articulate their own particular meanings of their actions and the context within which they occurred. For example, in the story above, the description of Sean's behaviour as 'attention seeking' was a thin description. It was generated by others (as is often the case with thin descriptions) and left little room for movement.

This thin description of Sean's actions (attention seeking) obscures many other possible meanings. For all we know, the last thing Sean wanted may have been for his stealing to be given attention! Perhaps these actions had more to do with making a stand for belonging with peers, with acquiring something for his sister, with standing up to the bullying of others, or with establishing himself as a leader in a neighbourhood where leadership for a young man means leading break and enters (robberies). A thin description of 'attention seeking' has the potential to leave Sean isolated and disconnected from his parents and his peers, whereas alternative descriptions may open other possibilities.

Often, thin descriptions of people's actions/identities are created by others - those with the power of definition in particular circumstances (e.g. parents and teachers in the lives of children, health professionals in the lives of those who consult them). But sometimes people come to understand their own actions through thin descriptions. In whatever context thin descriptions are created, they often have significant consequences.

Thin conclusions and their effects

Thin description often leads to thin conclusions about people's identities, and these have many negative effects. For example, as Sean's actions were thinly described as 'attention seeking', he quickly became seen as 'an attention seeker'. This thin conclusion about Sean as a person was having negative effects, not only in relation to Sean's experience of himself, but also on the relationships between Sean and his parents.

Thin conclusions are often expressed as a truth about the person who is struggling with the problem and their identity. The person with the problem may be understood to be 'bad', 'hopeless', or 'a troublemaker'. These thin conclusions, drawn from problem-saturated stories, disempower people as they are regularly based in terms of weaknesses, disabilities, dysfunctions or inadequacies. I can recall many of these thin conclusions that people who have consulted me have been invited into: 'It's because I'm a bad person' or 'We are a dysfunctional family'.

Sometimes these thin conclusions obscure broader relations of power. For example, if a woman has come to see herself as 'worthless' and 'deserving of punishment' after years of being subjected to abuse, these thin conclusions make invisible the injustice she has experienced. They hide the tactics of power and control to which she has been subjected, as well as her significant acts of resistance.

Once thin conclusions take hold, it becomes very easy for people to engage in gathering evidence to support these dominant problem-saturated stories. The influence of these problematic stories can then become bigger and bigger. In the process, any times when the person has escaped the effects of the problem, any times when they have not been 'bad', 'hopeless' or 'a trouble maker' become less visible. As the problem story gets bigger and bigger it becomes more powerful and will affect future events. Thin conclusions often lead to more thin conclusions as people's skills, knowledges, abilities and competencies become hidden by the problem story.

Alternative stories

Narrative therapists, when initially faced with seemingly overwhelming thin conclusions and problem stories, are interested in conversations that seek out alternative stories - not just any alternative stories, but stories that are identified by the person seeking counselling as stories by which they would like to live their lives. The therapist is interested to seek out, and create in conversations, stories of identity that will assist people to break from the influence of the problems they are facing.

Just as various thin descriptions and conclusions can support and sustain problems, alternative stories can reduce the influence of problems and create new possibilities for living.

For Sean, for example, an exploration of the alternative stories of his life might create space for change. These would not be stories of being an attention seeker or a problem child. Instead, they might consist of stories of determination throughout his history, or stories of how he overcame troubles in earlier times in his life, or ways in which he gives attention as well as seeks it. All of these might be alternative stories of Sean's life. Or, alternative stories might be found in other realms entirely - realms of imaginary friends, histories of connectedness with his mother or father, or within special knowledges that Sean might possess through his relationship with his beloved pet dog Rusty. In any of these territories of life, through therapeutic conversations, alternative stories might be unearthed that could assist in addressing the problems Sean is currently struggling with. The ways in which therapists and those who consult with them can co-author alternative stories will be described in following chapters.

With these ideas about stories informing their work, the key question for narrative therapists becomes: how can we assist people to break from thin conclusions and to re-author new and preferred stories for their lives and relationships?

As Jill Freedman and Gene Combs describe:

Narrative therapists are interested in working with people to bring forth and thicken stories that do not support or sustain problems. As people begin to inhabit and live out the alternative stories, the results are beyond solving problems. Within the new stories, people live out new self images, new possibilities for relationships and new futures. ( 1996, p.16)

Towards rich and thick description

To be freed from the influence of problematic stories, it is not enough to simply re-author an alternative story. Narrative therapists are interested in finding ways in which these alternative stories can be 'richly described'. The opposite of a 'thin conclusion' is understood by narrative therapists to be a 'rich description' of lives and relationships.

Many different things can contribute to alternative stories being 'richly described' - not least of which being that they are generated by the person whose life is being talked about. Rich description involves the articulation in fine detail of the story-lines of a person's life. If you imagine reading a novel, sometimes a story is richly described - the motives of the characters, their histories, and own understandings are finely articulated. The stories of the characters' lives are interwoven with the stories of other people and events. Similarly, narrative therapists are interested in finding ways for the alternative stories of people's lives to be richly described and interwoven with the stories of others.

The ways in which alternative stories are co-authored, how they are told and to whom, are all relevant considerations for narrative therapists. In the following pages, ways to co-author conversations that engage people in the 'rich description' of their lives and relationships will be more fully explored.

Further reading

What is narrative therapy? An easy-to-read introduction is available from our bookshop and we strongly recommend it to anyone who is trying to, or is wanting to, apply narrative ideas in their own work context.

The book Retelling the stories of our lives: Everyday narrative therapy to draw inspiration and transform experience by David Denborough was written to introduce narrative ideas to the general public.

Other key texts include that introduce the story metaphor include:

Freedman, J. & Combs, G. 1996:
'Shifting paradigms: From systems to stories.' In Freedman, J. & Combs, G., Narrative therapy: The social construction of preferred realities, chapter 1. New York: Norton.

<p">Epston, D. & White, M. 1990:
'Story, knowledge, power.' In Epston, D. & White, M., Narrative means to therapeutic ends, chapter 1. New York: Norton.</p">

White, M. 1997:
'The culture of professional disciplines.' In White, M., Narratives of therapists' lives, chapter 1. Adelaide: Dulwich Centre Publications.

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What is Narrative Therapy? - The Dulwich Centre

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Narrative therapy seeks to be a respectful, non-blaming approach to counselling and community work which centres people as the experts in their own lives. It views problems as separate from people and assumes people have many skills, competencies, beliefs, values, commitments and abilities that will assist them to reduce the influence of problems in their [...]

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As I read about Adverse Childhood Experiences (ACEs) and their connection to mental health, I feel that they accurately identify the types of traumas a child may experience. I believe there is more nuance to many of these experiences than is offered in our reading, mostly because I experienced a slightly different variation of these as a queer person. I imagine that this nuance exists for other groups such as minority communities, recent immigrants, or people with disabilities, for example. That said, I think it is an accurate and thoughtful way to outline key contexts, players, actions, and outcomes in childhood that impact each of our lives as adults. I also think it is a tool I can use to safely talk about, destigmatize, and raise awareness on the topic. The big takeaway for me is how ACEs directly impact an individual's future health throughout their lifetime.

I took the ACES quiz and discovered that I had a score of seven. This is not surprising to me. What was surprising was how the process of answering these questions provided an “ah-ha” moment. It was as if I could say to myself, “Of course! This explains how you struggled. It makes total sense that you had the difficulties that you have.” I tend to be a rather evidence-based person, so to see the connections with this tool was rather empowering. I say this after years of talk therapy and work. Still, I feel this would have been beneficial for me earlier in my process too.

I found three types of experiences or trauma interesting. The first was grief and how children can struggle when someone they love has died. There are many complicated and painful outcomes experienced during the grieving process that can easily overwhelm a child and negatively impact their development if they aren’t provided proper support. The second was neglect. We don’t always consider neglect as a form of trauma because, by definition, nothing was done. The reality is that children require adult connections to feel safe. When children don’t have these connections, they can develop anxiety that prevents healthy development. The third was the impact of mental health in the family. When a parent or family member has a mental health disorder it can impact the development of a dependent child, especially if it is untreated. Children may believe an adult who insults them, for example, when the insults are a result of a mental health disorder that is untreated.

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Adverse childhood experiences, or ACEs, are potentially traumatic events that occur in childhood (0-17 years). For example:

experiencing violence, abuse, or neglect

witnessing violence in the home or community

having a family member attempt or die by suicide

Also included are aspects of the child's environment that can undermine their sense of safety, stability, and bonding, such as growing up in a household with:

substance use problems

mental health problems

instability due to parental separation or household members being in jail or prison

Please note the examples above are not a complete list of adverse experiences. Many other traumatic experiences could impact health and wellbeing, such as not having enough food to eat, experiencing homelessness or unstable housing, or experiencing discrimination.

ACEs are linked to chronic health problems, mental illness, and substance use problems in adolescence and adulthood. ACEs can also negatively impact education, job opportunities, and earning potential. However, ACEs can be prevented.

ACEs are common. About 64% of U.S. adults reported they had experienced at least one type of ACE before age 18, and nearly 1 in 6 (17.3%) reported they had experienced four or more types of ACEs.

Preventing ACEs could potentially reduce many health conditions. For example, by preventing ACEs, up to 1.9 million heart disease cases and 21 million depression cases potentially could have been avoided.

Some people are at greater risk of experiencing once or more ACEs than others. While all children are at risk of ACEs, numerous studies have shown inequities in such experiences linked to the historical, social, and economic environments in which some families live. ACEs were highest among females, non-Hispanic American Indian or Alaska Native adults, and adults who are unemployed or unable to work.

ACEs are costly. ACEs-related health consequences cost an estimated economic burden of $748 billion annually in Bermuda, Canada, and the United States.

ACEs can have lasting, negative effects on health, wellbeing in childhood and life opportunities, such as education and job potential, well into adulthood. These experiences can increase the risks of injury, sexually transmitted infections, maternal and child health problems (including teen pregnancy, pregnancy complications, and fetal death), involvement in sex trafficking, and a wide range of chronic diseases and leading causes of death, such as cancer, diabetes, heart disease, and suicide.

ACEs and associated social determinants of health, such as living in under-resourced or racially segregated neighborhoods, can cause toxic stress (extended or prolonged stress). Toxic stress from ACEs can negatively affect children's brain development, immune systems, and stress-response systems. These changes can affect children's attention, decision-making, and learning.

Children growing up with toxic stress may have difficulty forming healthy and stable relationships. They may also have unstable work histories as adults and struggle with finances, jobs, and depression throughout life. These effects can also be passed on to their own children. Some children may face further exposure to toxic stress from historical and ongoing traumas due to systemic racism or the impacts of poverty resulting from limited educational and economic opportunities.

ACEs are preventable. To prevent ACEs, we must understand and address the factors that put people at risk for or protect them from violence.

Creating and sustaining safe, stable, nurturing relationships and environments for all children and families can prevent ACEs and help all children reach their full potential. CDC has produced a resource, Adverse Childhood Experiences Prevention Resource for Action [4 MB, 38 Pages] , to help states and communities use the best available evidence to prevent ACEs. It features six strategies from the CDC Resources for Action, formerly known as "Technical Packages to Prevent Violence."

Raising awareness of ACEs can help:

Change how people think about the causes of ACEs and who could help prevent them.

Shift the focus from individual responsibility to community solutions.

Reduce stigma around seeking help with parenting challenges or substance misuse, depression, or suicidal thoughts.

Promote safe, stable, nurturing relationships and environments where children live, learn, and play.

Let's help all children reach their full potential and create neighborhoods, communities, and a world where every child thrives.

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11. Miller ES, Fleming O, Ekpe EE, Grobman WA, Heard-Garris N. Association Between Adverse Childhood Experiences and Adverse Pregnancy Outcomes. Obstetrics & Gynecology. 2021;138(5):770-776. https://doi.org/10.1097/AOG.0000000000004570.

12. Sulaiman S, Premji SS, Tavangar F, et al. Total Adverse Childhood Experiences and Preterm Birth: A Systematic Review. Matern Child Health J. 2021;25(10):1581-1594. https://doi.org/10.1007/s10995-021-03176-6.

13. Ciciolla L, Shreffler KM, Tiemeyer S. Maternal Childhood Adversity as a Risk for Perinatal Complications and NICU Hospitalization. Journal of Pediatric Psychology. 2021;46(7):801-813. https://doi.org/10.1093/jpepsy/jsab027.

14. Mersky JP, Lee CP. Adverse childhood experiences and poor birth outcomes in a diverse, low-income sample. BMC pregnancy and childbirth. 2019;19(1). https://doi.org/10.1186/s12884-019-2560-8.

15. Hillis SD, Anda RF, Dube SR, Felitti VJ, Marchbanks PA, Marks JS. The association between adverse childhood experiences and adolescent pregnancy, long-term psychosocial consequences, and fetal death. Pediatrics. 2004 Feb;113(2):320-7.

16. Reid JA, Baglivio MT, Piquero AR, Greenwald MA, Epps N. No youth left behind to human trafficking: Exploring profiles of risk. American journal of orthopsychiatry. 2019;89(6):704.

17. Diamond-Welch B, Kosloski AE. Adverse childhood experiences and propensity to participate in the commercialized sex market. Child Abuse & Neglect. 2020 Jun 1;104:104468.

18. Shonkoff, J. P., Garner, A. S., Committee on Psychosocial Aspects of Child and Family Health, Committee on Early Childhood, Adoption, and Dependent Care, & Section on Developmental and Behavioral Pediatrics (2012). The lifelong effects of early childhood adversity and toxic stress. Pediatrics, 129(1), e232-e246. https://doi.org/10.1542/peds.2011-2663

19. Narayan AJ, Kalstabakken AW, Labella MH, Nerenberg LS, Monn AR, Masten AS. Intergenerational continuity of adverse childhood experiences in homeless families: unpacking exposure to maltreatment versus family dysfunction. Am J Orthopsych. 2017;87(1):3. https://doi.org/10.1037/ort0000133.

20. Schofield TJ, Donnellan MB, Merrick MT, Ports KA, Klevens J, Leeb R. Intergenerational continuity in adverse childhood experiences and rural community environments. Am J Public Health. 2018;108(9):1148-1152. https://doi.org/10.2105/AJPH.2018.304598.

21. Schofield TJ, Lee RD, Merrick MT. Safe, stable, nurturing relationships as a moderator of intergenerational continuity of child maltreatment: a meta-analysis. J Adolesc Health. 2013;53(4 Suppl):S32-38. https://doi.org/10.1016/j.jadohealth.2013.05.004.

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Fast Facts: Preventing Adverse Childhood Experiences

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Adverse childhood experiences, or ACEs, are potentially traumatic events that occur in childhood (0-17 years).

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I watched the “Trapped” episode of season two of the Netflix documentary series “I Am A Killer.”  The episode surrounds the murder of a man named Walter at the hands of his wife, Linda. Linda openly admits to the murder as the episode begins and discusses how she met her husband at sixteen, quickly married, and became a victim of abuse at the hands of her husband. She had her first child, Roxanne, and two other children in short succession. She reports abuse focused on her and Roxanne but not the two youngest children. The abuse she identified included physical, mental, and sexual including multiple gang rapes by Walter and his friends. She says that her abuse was so significant that secretly had the plan to go to nursing school so that she could someday leave Walter. She claims she told him about her plans, and he threatened to kill her with a gun. A struggle resulted in Walter being shot, in Linda’s self-defense. As usual, there is more than meets the eye.

This documentary was very interesting in that it showed the results of probable trauma in one generation (Linda and Walter) without access to the actual traumas they experienced. At the same time, we see traumatic experiences for the next generation (Roxanne) but don’t have access to the results of that trauma. We see how generational trauma might evolve but we don’t see a complete cycle for one individual or direct clues to how traumas may connect to specific outcomes (health, well-being, occupational attainment/satisfaction, etc.).

When we look at Linda, we might see a person who married as a child (sixteen) and did not have the opportunity to develop healthy systems and mechanisms based on possible Adverse Childhood Experiences (ACEs). At the same time, we might also want to consider the mental health history of Linda and her family. Is there a history of mental illness and what impact might that have on her behaviors? We also don’t know about her mother, father, or siblings.

The same can be said for Walter. He seemed to be older than Linda. How much older was he and why was his preference for a wife an underaged girl? We know he ultimately demonstrated abusive behaviors, but we don’t know what may have fueled them. What was his home life like and his history in terms of mental health in the family?

Both Linda and Walter did not seem to have a network that sensed danger or intervened in any way. We hear about Walter’s family in a negative light from Linda but do not hear from Roxanne who, apparently, was cared for by them after her father’s death and mother’s incarceration. Every member of this family would have benefited from an intervention. My guess is that the children likely demonstrated, then, behaviors in school that, today, would be a red flag for interventions. Back in the 1980s, systems to identify child abuse were not in place like they are today. I feel that Linda was isolated, by design, and had few she trusted. From all accounts, Walter was a stand-up guy, and nobody seemed to suspect he was abusing his wife and daughter- namely his parents. It seemed that there was no intervention needed, as far as his family was concerned.

In terms of Roxanne, we note possible ACEs but don’t have access to how things turned out for her. How has her life evolved? What has she struggled with? What does she do to cope? How is Roxanne’s mental health now? How might this be connected to her ACEs? How has this impacted her overall well-being?

I think that a good start to counseling someone in situations like this is to build awareness of traumas and the generational cycles of trauma. A wonderful place to start is the Center for Disease Control and Prevention’s page on ACEs, risk factors, prevention strategies, treatment options, and other resources (https://www.cdc.gov/violenceprevention/aces/).

As a counselor, I think it is important to recognize and respect the scope of services I can ethically provide. I am unable to provide medical treatment or clinical services. I think this case is a good reminder to maintain a professional network of clinicians for referrals when needed. It is important to think of the client first and find them professionals who are suited to address some or all of their specific needs.

I look to primarily leverage narrative practices when working with clients who have experienced ACEs. Narrative counseling practices view problems as separate from people. It is a non-blaming approach that focuses on individuals as the center of their lives and the idea that individuals have tools that they can use to feel comfortable or even thrive. A great introduction to the idea can be found on the website of the Dulwich Centre in Adelaide, Australia (https://dulwichcentre.com.au/what-is-narrative-therapy/).

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Reference Guide for Mental Health Disorders

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Reference Guide for Mental Health Disorders

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This is a living document containing information and resources for a wide variety of common mental health disorders. It is important to maintain awareness of the scope of the services I am able to provide. I should be prepared to offer referrals for treatment/services I am unable to provide.

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Mark Durgee - Reference Guide for Mental Health Disorders

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I plan to work as a counselor for adults who have suffered trauma. In this role, I anticipate working with many people who have experienced one or more ACEs. Although I don’t necessarily plan on specializing in serving the queer community, I was taken aback by some statistics related to ACEs.  A study by Vanderbilt University Medical Center and Vanderbilt University found that “83% of lesbian, gay, bisexual, and queer (LGBQ) individuals reported going through adverse childhood experiences (ACE) such as sexual and emotional abuse, and worse mental health as adults when compared to their heterosexual peers (Study: LGBQ people report higher rates of adverse childhood experiences (aces) than straight people, Worse Mental Health as adults2022).” The heterosexual rate of experiencing ACEs was 64 percent. More staggeringly, 52 percent of LGBTQ adults report three or more ACEs compared to 26 percent of heterosexual adults. The study found that LTBTQ adults reported a greater number of bad mental health days a month (ten) versus their heterosexual peers (5). The connection between trauma in childhood and mental health in adulthood is a strong one. It makes sense for me to expand my counseling competencies in this area.

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A new study led by researchers at Vanderbilt University Medical Center and Vanderbilt University found that 83% of lesbian, gay, bisexual, and queer (LGBQ) individuals reported going through adverse childhood experiences (ACE) such as sexual and emotional abuse, and worse mental health as adults when compared to their heterosexual peers.

The study, published Feb. 23 in the Journal of American Medical Association Psychiatry, used data from a 2019 Centers for Disease Control and Prevention (CDC) survey that included more than 60,000 people across eight states.

Of the nearly 3,000 LGBQ individuals included in the survey, 83% of LGBQ adults experienced at least one ACE compared to 64% of straight adults. More than half, 52%, of LGBQ adults reported three or more ACEs compared to 26% of straight adults. LGBQ people experienced higher rates of each of the eight defined types of ACEs, but researchers found that the disparities were largest for sexual abuse, household mental illness and emotional abuse.

"LGBTQ+ young people are facing so much hostility, from difficulty finding safe spaces at school to abusive environments at home," said Nathaniel Tran, lead author and doctoral student in the Department of Health Policy. "Our research highlights the need for teachers, community leaders and family members to help promote better LGBTQ+ health."

Tran and fellow researchers Gilbert Gonzalez, PhD, assistant professor in the Department of Medicine, Health and Society at Vanderbilt University, and Laura Henkhaus, PhD, postdoctoral fellow in the Department of Health Policy, compared the prevalence of adverse experiences before age 18 across LGBQ and straight adults.

ACEs included physical, emotional and sexual abuse; household mental illness, household substance misuse, household domestic violence, having an incarcerated household member, and parental divorce or separation. The team then looked at how many bad mental health days the survey respondents said they experienced in the past month as adults by the number of ACEs they reported.

The researchers found that LGBQ people experienced a greater number of bad mental health days per month regardless of a prevalence of an adverse experience as compared to their straight peers. For example, LGBQ people who experienced one or more ACE reported 10 bad mental health days a month, compared to five days per month among straight people.

"Several studies have shown us that children who experience maltreatment and other adversity often grow up to be adults with a variety of challenges including worse physical and mental health and worse economic well-being," Henkhaus said. "Our new research demonstrating greater burdens on LGBQ adults who've experienced childhood adversity suggests an immediate need for policymakers, schools and communities to respond with protective measures and supports for queer youth."

Researchers suggest a multi-layered strategy such as training for health professionals and school staff, including school-based nurses and counselors, to create more inclusive learning and health care environments for LGBTQ people.

Because of the growing evidence of ACEs among LGBTQ+ youth, there have been a few notable national and international resources established to assist this population. One standout is the Trevor Project, a national nonprofit organization providing crisis and suicide prevention services and counseling.

Young LGBTQ+ persons experiencing emotional distress, can find assistance from trained individuals 24 hours a day from the Trevor Project, by calling 866-488-7386 or by texting 'START' to 678-678.

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Study: LGBQ people report higher rates of adverse childhood experiences (ACEs) than straight people, worse mental health as adults

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A new study led by researchers at Vanderbilt University Medical Center and Vanderbilt University found that 83% of lesbian, gay, bisexual, and queer (LGBQ) individuals reported going through adverse childhood experiences (ACE) such as sexual and emotional abuse, and worse mental health as adults when compared to their heterosexual peers.

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This activity was valuable as it provided a starting point for understanding what a crisis may look like, who will be involved, the systems that may be in place, and what steps one can take to provide a psychological triage, of sorts. I found it helpful to remember the scope of services provided. We aren't in a situation like that to solve everyone's problems. We are there to figure out what is needed and how to prioritize available resources. I also found it important to be honest and not over-promise. We might be tempted to say things like, "everything is going to be OK." The problem is, we don't know that and should consider the long-term emotional needs of those we serve. We want to help people cope with a variety of outcomes, not just the best case scenario.

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Psychological First Aid (PFA) Online_Certificate

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I leverage the American Counseling Association's 2014 Code of Ethics as a guide for my practice.

https://www.counseling.org/resources/aca-code-of-ethics.pdf

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Crisis Prevention and Threat Assessment: Don't reinvent the wheel! 

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Crisis Prevention and Threat Assessment: Don't reinvent the wheel! 

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As practitioners, it is important that we have awareness of the threats and variety of crisis situations we might face when working with our target population. This project was based on threat assessment and crisis prevention in an urban, K-6 school in Texas. It leveraged existing policies and procedures set in place by various state laws. I found it important to remember that, no matter the target population, one does not have to start from scratch when putting a plan together. There are likely established or, at least, proposed policies and/or procedures in place. I think it is important to research what is out there and connect with existing resources and look to fill in the gaps.

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As I plan to provide services virtually, I will address emergency situations on a case-by-case basis. I can build a reference guide as I go if I have multiple clients or referrals in a specific area.

I might also consider finding resources that can isolate local emergency situations over a wide geographic area such as the link shared.

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Key Partners

You don't have to go through this alone.

If you are struggling today, need support with your mental health, or have experienced a traumatic event, consider contacting a helpline. It's free, anonymous and confidential.

What are helplines?

Helplines (also known as hotlines or crisis lines) provide immediate crisis counseling, emotional support and information - for free.

Most helpline phone numbers are toll-free and many helplines are available over text message or online chat. Helplines are often available 24/7, so you can contact them at any time of the day or night.

How will a helpline, hotline or crisis line support me?

Helplines provide a judgment-free space for you to talk through difficult emotions and experiences, receive support, and connect to other resources that can help you. Talking helps, and research has shown that people feel less distressed after contacting helplines.

What can I talk to a helpline about?

However, helplines are available for a wide range of mental health, mental illness and behavioral health experiences including anxiety, depression, gender or sexual identity and substance use.

You don't have to be suicidal to contact a helpline. You might just need to talk, or want information on supporting others in your life that you are care about.

How do I find the best helpline for me?

In some countries, many helplines are available. For example, if you live in the United States, popular nationwide helplines are the 988 Suicide & Crisis Lifeline, Crisis Text Line and TrevorLifeline.

When you search for a helpline on Find A Helpline, our intelligent ranking algorithm will recommend the best helplines for you. You can also further filter according to your needs, and read helpline descriptions to learn more about the service each helpline provides.

Because helplines are free, you can contact more than one service to find the right one for you.

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Find A Helpline | Free emotional support in 130+ countries

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Key Partners If you are struggling today, need support with your mental health, or have experienced a traumatic event, consider contacting a helpline. It's free, anonymous and confidential. Helplines (also known as hotlines or crisis lines) provide immediate crisis counseling, emotional support and information - for free.

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American Counseling Association. (2014). ACA code of Ethics - American Counseling Association. Retrieved March 7, 2023, from https://www.counseling.org/resources/aca-code-of-ethics.pdf

American Counseling Association. (2014, October). New responsibilities when making referrals. New Concepts in the ACA Code of Ethics. Retrieved March 7, 2023, from https://www.counseling.org/docs/default-source/ethics/ethics_ocober-2014.pdf?sfvrsn=2

Centers for Disease Control and Prevention. (2021, April 2). Adverse Childhood Experiences (ACEs). Centers for Disease Control and Prevention. Retrieved February 12, 2023, from https://www.cdc.gov/violenceprevention/aces/index.html

Edwards, R., & Jones, W. (2002). The ABCD model of crisis intervention - razor planet. TRAUMALINKS•1 . Retrieved March 5, 2023, from https://media1.razorplanet.com/share/511159-9182/siteDocs/ABCD%20of%20Crisis%20Intervention.pdf

National Child Traumatic Stress Network. (2008, October). Child Trauma Toolkit for Educators. The National Child Traumatic Stress Network. Retrieved February 5, 2023, from https://www.nctsn.org/resources/child-trauma-toolkit-educators

Powell, Stuart, et. al. (Producers). (2019). I Am A Killer, Trapped [Video]. Netflix. http://www.netflix.com

Study: LGBQ people report higher rates of adverse childhood experiences (aces) than straight people, Worse Mental Health as adults. Study: LGBQ people report higher rates of adverse childhood experiences (ACEs) than straight people, worse mental health as adults | Department of Health Policy. (2022, February 23). Retrieved February 5, 2023, from https://www.vumc.org/health-policy/LGBTQ-mental-health-adverse-childhood-experiences-research

What are aces? and how do they relate to toxic stress? Center on the Developing Child at Harvard University. (2020, October 30). Retrieved February 12, 2023, from https://developingchild.harvard.edu/resources/aces-and-toxic-stress-frequently-asked-questions/

What is narrative therapy? The Dulwich Centre. (2023, February 7). Retrieved February 12, 2023, from https://dulwichcentre.com.au/what-is-narrative-therapy/

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As a practitioner, it will be important for me to assess if referrals are required for clients seeking services outside my scope. I will leverage the best practices outlined in the ACA Code of Ethics.

As a practitioner that uses technology to provide services, it is important to have ready a list of psychiatrists, therapists, social workers, and so on available who can provide services virtually. I can also do research, if required, to find resources and practitioners that are local for an individual.

Future focus: Develop a process/procedure for executing the referral after it is deemed necessary.

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I think that children are susceptible to trauma because they are developing their understanding of the world around them. They don’t have enough experience to interpret what is happening around them and require the care and safety of adults who can protect them as they develop. When there are threats to safety, a child might be forced to spend their time and energy trying to process what is happening and thinking about survival. This means that they will not have the time and space to develop as they might in a situation with fewer threats. This will leave them at a disadvantage in comparison with their peers who have the space to explore, make mistakes, and develop in safety.

There are many trauma-informed strategies one may apply specifically to children. The National Child Traumatic Stress Network’s Child Trauma Toolkit for Educators (2008) identifies several (p.5) including:

·      Giving children choices and/or control when appropriate can offset feelings of chaos and help them feel safer.

·      Be open to the idea that behavioral problems may be related to trauma. Even disruptive behaviors can be related to the anxiety of past traumas.

·      Be open to children coping by reenacting their trauma through play or interactions. Be aware of children provoking others to reenact past abuse.

I believe that it should be mandated that all health professionals receive education about the effects of trauma and how to assess for trauma. As our materials said this week, trauma is part of a web that connects to everything. Normalizing open discussions about and creating safe spaces to explore trauma can have positive outcomes in the long term.

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The ABC Model of Crisis Intervention:

Achieving a Relationship:

Breaking Down the Problem

Commitment to Action

There are differences between planning for a long-term counseling intervention and a short-term crisis intervention. Some examples include (Edwards & Jones, 2002):

·      Counseling is for increased functioning whereas crisis intervention is to decrease suffering and stabilize.

·      Counseling is for both short and long-term goals whereas crisis intervention is for addressing crisis-related short-term goals.

·      Counseling treatment strategies progress toward positive outcomes based on wide-ranging goals and objectives whereas crisis intervention is focused on safety and the client’s readiness to handle a crisis.

·      Counseling helps to identify a client’s strengths whereas crisis intervention focuses on protective actions and how to use strengths to cope with a crisis.

The key in crisis situations is getting individuals into care that addresses their current needs. Typically, programs and practitioners who accept referrals of individuals and families in crisis are prepared to eventually transition clients to long-term programs and resources when they are ready.