Sibling Abuse: A Study of School Counselors’ Shared Attitudes and Beliefs

Diane M. Stutey

The impact of sibling abuse on children and adolescents is rarely contemplated. Counselors are in a position to advocate for all children and protect them from harm; yet one source of harm that counseling practitioners and educators might be unaware of stems from violence between siblings, which can become abusive. In this article, findings are presented from a phenomenological study examining eight practicing school counselors’ attitudes and beliefs about sibling abuse and the contexts or situations that have influenced them. Seven themes emerged supporting school counselors’ perceptions of their role in responding to sibling abuse and their beliefs about factors contributing to sibling abuse. Recommendations for advocacy for children and adolescents are offered for counselor educators, counselors-in-training and counseling practitioners, school counselors in particular.

Keywords: sibling abuse, school counselors, advocacy, children, adolescents 

 

All counselors advocate for their clients (American Counseling Association [ACA], 2014; Ratts & Hutchins, 2009). School counselors, in particular, often perform a fundamental role in advocating for the well-being of children and adolescents (American School Counselor Association [ASCA], 2012; Ratts, DeKruyf, & Chen-Hayes, 2007). A unique aspect of practice for school counselors is that they work with children and adolescents on a daily basis and often over a longer period of time than other counselors in the community. School counselors’ close proximity to children and adolescents within the school system also allows them to advocate for students systematically year after year.

 

     One important way that school counselors can advocate for students is by protecting them from harm. In accordance with the Child Abuse Prevention and Treatment Act (Children’s Bureau, 2010), the ASCA Ethical Standards (2010) and the ACA Code of Ethics (2014), school counselors must report any suspicion of child abuse or neglect to child protective service (CPS) agencies. School counselors often receive training on abuse recognition and reporting (Alvarez, Donohue, Kenny, Cavanagh, & Romero, 2005; Kominkiewicz, 2004; Lambie, 2005; Minard, 1993). However, child abuse training is typically exclusively focused on parent-to-child abuse or abuse by another adult over the age of 18.

 

     Abuse of children by adults may not be as prevalent as other forms of abuse against children. A less commonly explored form of family violence is sibling abuse. In the past, sibling abuse was considered a normal rite of passage that most children experience and was misidentified as sibling rivalry (Phillips, Phillips, Grupp, & Trigg, 2009). However, results from National Family Violence Surveys indicated that violence between siblings was extensive and harmful (as cited in Straus, Gelles, & Steinmetz, 1980). Wiehe (2002) summarized that participants in these surveys revealed the rates of sibling abuse “make the high rates of other forms of family violence, such as parents abusing children or spouses abusing each other, seem modest by comparison” (p. 2). In addition to potentially being the most prevalent form of abuse, it also has been determined that violence between siblings was the least reported and researched form of family abuse (Eriksen & Jensen, 2006, 2009). Stutey (2013) posited that a lack of federal laws and protocol for reporting sibling abuse, as well as the absence of a definition for sibling abuse in the school counseling literature, might contribute to this problem.

 

For this study, the term sibling aggression was utilized to represent a continuum of behaviors beginning with mild aggression (i.e., competition and conflict) and progressing to severe aggression (i.e., violence and abuse; Caspi, 2012). Sibling abuse and sibling violence were both viewed as severe forms of sibling aggression, with sibling abuse being the most severe. Sibling abuse has been defined as the unilateral physical, emotional or sexual harm of one sibling by another (Caspi, 2012). Researchers have suggested that 3–6% of children have experienced severe sibling abuse that might include using weapons or objects to inflict pain (Button & Gealt, 2010.

 

     Sibling violence also has been considered a severe form of sibling aggression resulting in physical, emotional or sexual harm, but differs from sibling abuse because it is defined as bidirectional, or mutual, aggression between siblings (Caspi, 2012). The literature on sibling violence posits that 30–80% of children experience some form of violence by a sibling (Button & Gealt, 2010). Whether a product of sibling abuse or sibling violence, both forms of aggression result in emotional and psychological consequences for children (Stutey, 2013). For the purpose of this research study, Kiselica and Morrill-Richards’ (2007) definition of a sibling was utilized and was inclusive of the following: “biological siblings (share both parents), half-siblings (one parent in common), step-siblings (connected through marriage of parents), adoptive siblings, foster siblings (joined through a common guardian) or fictive siblings (may not be biologically related but are considered siblings)” (p. 149).        

 

    Even when school counselors are able to make the distinction between less severe sibling aggression and sibling violence or abuse, there might be some confusion about how to address this phenomenon. The federal laws and statutes discussed previously do not specifically address or protect against abuse between siblings. While the Child Abuse Prevention and Treatment Act (Children’s Bureau, 2010) provided clear guidelines for school counselors on how and when to report suspected child abuse by an adult, the same cannot be said for abuse by a sibling. Counselors in the clinical setting are likely to encounter this same predicament.

 

     A review of the literature revealed that although ongoing research has been conducted by practitioners in the field of family violence and the medical field, particularly nursing (Button & Gealt, 2010; Caffaro, 2011; Caffaro & Conn-Caffaro, 1998; Caspi, 2012; Eriksen & Jensen, 2006, 2009; Finkelhor, Turner, & Ormrod, 2006; Finkelhor, Turner, Ormrod, Hamby, & Kracke, 2009; Goodwin & Roscoe, 1990; Morrill & Bachman, 2013; Skinner & Kowalski, 2013; Straus et al., 1980; Tucker, Finkelhor, Turner, & Shattuck, 2013; Wiehe, 1997), none of the research appeared in any of the professional literature for counselors with the exception of Kiselica and Morrill-Richards (2007). In addition, while all counselors are ethically required to promote wellness and protect students from harm, there was no specific research in the counseling literature that addressed training for counselors on how to identify and intervene with children experiencing sibling abuse and violence.

 

    The combination of possible normalizing attitudes toward sibling rivalry coupled with a lack of training and guidelines on identification and intervention is problematic. Furthermore, researchers have confirmed that survivors of childhood sibling abuse exhibit many long-term mental health concerns similar to those of children abused by an adult, such as depression, drug and alcohol abuse, low self-esteem, at-risk sexual behaviors, and continuing the cycle of violence in future relationships (Noland, Liller, McDermott, Coulter, & Seraphine, 2004; Oshri, Tubman, & Burnette, 2012; Simonelli, Mullis, Elliott, & Pierce, 2002; Tucker et al., 2013; Waite & Shewokis, 2012; Wiehe, 2002). A lack of awareness and professional training standards about sibling abuse might ultimately result in counselors not reporting this as abuse and lead to long-term psychological harm to children and adolescents.

 

The purpose of this study was to examine and gain further insight into and awareness of current school counselors’ shared experiences with sibling abuse. Based on the review of the literature, it also was imperative to understand whether there might be exterior influences impacting school counselors’ ability to work with students experiencing sibling abuse. The two overarching questions for this study were the following: (1) How do school counselors describe their attitudes and beliefs about sibling abuse? (2) What contexts or situations have influenced or affected school counselors’ attitudes and beliefs about sibling abuse?

Methodology
According to Trusty (2011), “if little is known about a research area or target population, it is likely that a qualitative study would be needed first” (p. 262) before utilizing a quantitative approach. Thus, the researcher chose a qualitative design because no current studies have been conducted with school counselors about sibling abuse. Phenomenology was the most appropriate methodology because it is grounded in the paradigmatic assumption of constructivism and the belief that multiple realities exist and can be explored through in-depth descriptions of participants’ perspectives and lived experiences (Hays & Wood, 2011). Phenomenology was utilized as information was gathered and described, and meaning was interpreted from the data in order to better understand school counselors’ shared attitudes and beliefs about sibling abuse and its relevant contexts or situations.
Participants

This study utilized a purposeful sample of practicing school counselors across one Western state. By choosing a single state, the specific state laws and statutes in place to protect children from abuse and neglect were available to be thoroughly explored. In addition, each participant had at least 2 years of experience as a practicing school counselor. Soliciting school counselors with at least 2 years of experience increased the likelihood that the participants had experience working with children and abuse, and perhaps sibling abuse. Participants were solicited through local and regional professional organizations such as local school districts and the state school counseling association. To gain a balanced sample, participants were recruited at all three grade levels and from a variety of geographical locations and districts across one Western state.

 

The participants in this study consisted of eight female school counselors. Two of the participants self-identified as European and the remaining six self-identified as Caucasian. The age range of these participants was 35–58 years old with a mean age of 44 years old. Participants reported a range of 4–21 years of experience as school counselors with a mean of 10 years of experience. All participants except for one graduated from a CACREP-accredited master’s degree counseling program between the years of 1989 and 2009. One participant later earned a PhD in higher education. Five of the participants identified their schools as urban and three as suburban. At the time of participation, three participants worked at the elementary level, two at the middle school level and three at the high school level. A Graham Fund Grant was received to give participants a $25 gift card for their participation in this study.

 

Procedures

After obtaining Institutional Review Board approval, the researcher secured informed consent and conducted two audiotaped interviews with each participant, allowing 3–4 weeks between interviews. First interviews ranged from 45–60 minutes in length and second interviews ranged from 30–45 minutes in length. The second interview gave participants the opportunity to share any further insights once they had had time to reflect upon the phenomena of sibling abuse and allowed for prolonged engagement, which built trust with participants and created an opportunity to check for misinformation (Creswell, 2007).

 

When possible, it is recommended that in-person interviews be conducted in order to gain as much information as possible, both verbally and nonverbally (Creswell, 2007; Given, 2008). Based on their availability and comfort level, six of the first interviewees chose in-person interviews, one participant opted for a Skype interview and one was interviewed by telephone. In the second interviews, seven of the eight participants interviewed in person and one participant opted for a second telephone interview.

 

Story vignettes were created to be utilized alongside the first semistructured individual interview. Because sibling abuse is a relatively unknown topic, vignettes allowed participants to respond to hypothetical questions about sibling abuse. Hypothetical questions allowed participants to discuss what they might do in a particular situation (Merriam, 1998) and ensured that all participants would be able to share their attitudes and beliefs whether or not they had encountered a student experiencing sibling abuse. The researcher utilized Heverly, Fitt, and Newman’s (1984) empirical model to create two story vignettes that varied on three factors: gender, age of the student, and the type of abuse being presented (physical and emotional or relational). “Vignettes are partial descriptions of life situations used in research and education as a strategy to elicit participants’ attitudes, judgments, beliefs, knowledge, opinions or decisions” (Brauer et al., 2009, p. 1938). (Interview questions and story vignettes are available from the author.)

 

Data Analysis and Trustworthiness

All data were collected by one researcher and transcribed by a third party. Data were analyzed and independently coded at two levels by the researcher. In the first level of coding, shorthand was assigned to data to identify important information about the data, and in the second level, interpretive constructs were identified (Merriam, 1998). Throughout both levels of coding, the specific techniques for analyzing phenomenological data of horizontalizing, clustering horizons, and textural and structural description were utilized (Moustakas, 1994).

 

Several techniques were used to ensure the trustworthiness and rigor of data collection and analysis. First, the researcher conducted two member checks. According to Guba and Lincoln (1989), a member check is the most important technique that researchers can use to establish credibility. Participants received transcripts from their individual interviews and initial emerging and final themes. Participants were allowed to remove or further discuss any data from their transcript or the initial and final themes that did not fit their perspective and experience of the phenomenon.

 

Next, the researcher utilized peer reviewers. Two peer reviewers provided feedback at three points throughout the data collection and analysis—after the first two individual interviews, at the end of the first round of interviews and at the end of the second round of interviews. Peer reviewers had access to initial emerging themes and final themes, the researcher’s journal, and coding documentation in order to inform their feedback provided to the researcher throughout the data collection and analysis process. The researcher conducted a debriefing session after receiving feedback from each of the peer reviewers. Lincoln and Guba (1985) recommended that peer debriefing sessions be documented. Therefore, the researcher tracked feedback and subsequent changes to emerging themes in a researcher’s journal as part of an audit trail.

 

Finally, the researcher utilized bridling to establish trustworthiness and acknowledge prior and current experiences with sibling abuse. “Bridling is a reflexive project, is a departure from the often used phenomenological technique of bracketing one’s pre-understandings, and offers ways to imagine a less deterministic view of validity in phenomenological research” (Vagle, 2009, p. 586, emphasis in original). Bridling was chosen over bracketing because the researcher had personal and professional experiences with sibling abuse making it unlikely, if not impossible, to put aside all biases and assumptions.

 

The researcher developed a researcher’s stance and kept a researcher’s journal throughout the data collection and analysis to bridle and manage biases and assumptions. A summary of the researcher’s stance is provided below. Presentation of these assumptions and biases was an effort to increase awareness about what might inadvertently influence this study; it was not an attempt to change or dismiss assumptions or biases, but rather to bridle how these might impact the collection and analysis of the data.

Researcher’s Stance

 

The researcher was interested in sibling abuse for several intertwined reasons. As a school counselor for 8 years, the researcher worked with many children and their siblings around issues that were commonly referred to as sibling rivalry. However, the researcher received no training or academic coursework about sibling abuse and in retrospect acknowledged that sibling abuse or violence may have been overlooked with several students. In addition, the researcher is the middle child of five siblings and experienced mild sibling aggression beyond developmentally appropriate sibling rivalry. The researcher acknowledged that these professional and personal experiences furthered an interest to learn more about sibling abuse. The researcher engaged in ongoing reflexivity and continued to engage in bridling professional and personal experiences with sibling abuse throughout the data collection and analysis process.

 

Results

 

A total of seven themes emerged from the two interviews with the participants. The seven themes, as well as corresponding subthemes, have been organized into two overarching categories: (a) responding to sibling abuse, and (b) factors contributing to sibling abuse (see Figure 1). The first category represented participants’ perception of their role as school counselors to respond to students experiencing sibling abuse and ways in which to support families. The overarching category of responding to sibling abuse was supported by the following four themes: keeping students safe, defining the line, multiple victims and needs, and education and awareness. The second overarching category represented what participants perceived as contributing factors that might influence and impact how they viewed and responded to students experiencing sibling abuse. The second overarching category, factors contributing to sibling abuse, was supported by the following four themes: education and awareness, sibling bond, learned violence, and systemic barriers. It was determined that one of the seven themes (education and awareness) overlapped and fit into both of the overarching categories. Descriptions of the themes and accompanying subthemes are provided with support from participants. Participants chose pseudonyms to be used throughout their participation in this research study.

 

Responding to Sibling Abuse
Keeping students safe.
The first theme that emerged from the participant data was keeping students safe. This theme was defined as participants’ shared beliefs that as school counselors, they are responsible to respond and to advocate on behalf of all students in order to keep them safe from psychological harm. Participants shared that abuse by a sibling was “no different” than a parent abusing a child. However, only one of the eight participants shared that she had responded to sibling abuse by following specific district protocol outlining how school counselors should report sibling abuse. Of the remaining seven participants, four had encountered one or more instances of sibling abuse at their school and responded in a variety of ways to keep students safe. The remaining three participants hypothesized what they might do if sibling abuse was suspected, but reported that they had never directly spoken to a student about sibling abuse. Two subthemes emerged from the participants’ descriptions of keeping students safe—advocacy and collaboration.

 

     Advocacy. First, participants shared that they perceived their role as being responsible for keeping students safe by responding through advocacy. For example, Grace shared, “My number-one role is to advocate for students and make sure that they are safe.” Laura stated, “I just think before we can do much of anything else, we have to keep them safe—so that is very important.” She mentioned that for some children, “school is the safe place that they have to go.” Many participants stated that one of the key ways in which they would advocate for children experiencing any kind of abuse, including sibling, was by contacting CPS or law enforcement. Margaret shared, “I think you definitely need to notify law enforcement that it [sibling abuse] is something that is happening in the home and then make a call to social services as well.”
Collaboration. While participants endorsed that one way to keep students safe is to advocate and report sibling abuse to CPS agencies or local law enforcement authorities, they acknowledged that these strategies do not always stop the problem. Therefore, to keep students safe, participants shared that they also believed they needed to collaborate with parents and outside agencies to put support systems in place for the victim, offender and family. Valerie shared, “I feel like my best shot is to talk to the parents to see if there is something they can do to protect the child at home.” Tiffany noted, “If I can get the family on board, then hopefully we can get a lot more done.” At the same time, participants discussed that collaborating with parents can be problematic, especially if there is a history of family violence or parents dismiss sibling abuse as a serious problem. Ty mentioned, “I can help with the [sibling] competition and I can help with the conflict, but the violence and abuse are much too severe for a casual relationship—they need longer term help.” Therefore, beyond collaborating with parents, participants shared that to keep students safe from sibling violence and abuse, they also may need to solicit help from community-based counselors.

 

     Defining the line. The second theme that emerged from the participant data was defining the line. This theme was defined as participants’ shared attitudes and beliefs about how they delineated between healthy sibling rivalry and sibling violence or abuse. Participants endorsed that sibling abuse or violence was often viewed as “normal” in society, making it more difficult to identify and therefore report. Also, participants shared that students and parents may not differentiate harmful sibling aggression from healthy rivalry, and therefore students are likely being harmed. Although participants believed it was their role to respond to students, they shared that sibling abuse is difficult to define and consequently report, which makes it a complex problem. The following two subthemes emerged from the participants’ descriptions of defining the line: normal sibling rivalry, and violence and abuse.

     Normal sibling rivalry. First, the counselors discussed normal sibling rivalry as healthy and a “normal part of growing up,” which presented opportunities for school counselors to respond through lessons on conflict resolution. Lee shared, “I believe in competition, I believe in conflict over the biggest cookie or bathroom time, TV time or choosing different things. . . . I think that is all natural and normal and healthy, and it helps us figure out life.” Holly shared, “In conflict, you learn a lot about how to resolve conflict with your siblings and it is normal to have conflict, especially minor conflict.” Participants shared that absence of a firm definition for where to “draw this line” between sibling rivalry and violence or abuse often negatively affected the ways in which they responded.

 

     Violence and abuse. Participants shared varying views on what differentiated sibling violence from abuse; however, most shared that sibling violence was a mutual act between siblings while abuse consisted of a power differential between siblings. Valerie stated, “Abuse is when one of them who is bigger, meaner, tougher, beats up the other one, and the other one can’t defend themselves.” She further explained, “When it’s violent, they can each give and take, but when it’s abusive, one of them can’t protect themselves or dish out as much as they get.” Participants struggled to define how often a behavior had to occur for it to be considered abuse. Tiffany asked, “Do they have to get punched in the face three times, does that make it abuse? So it’s just a weird line. Is there a line? I really don’t know.” Grace mentioned the need for “a clear definition for school counselors and maybe examples and how to go about addressing it.”

 

     Multiple victims and needs. The third theme that emerged from the participant data was multiple victims and needs. This theme was defined as participants’ shared attitudes and beliefs about responding not only to the primary victim of sibling abuse, but also responding to others such as the sibling offender or other victims. Participants believed that school counselors focus primarily on working with the student being harmed in cases of child abuse. However, participants felt equal responsibility for the sibling offender’s well-being and academic success as they did for the victim’s. Participants who had worked with sibling offenders in the schools noted concern that these students might also be “victim[s] of abuse themselves.” The following two subthemes emerged from the participants’ descriptions of multiple victims and needs: sibling offender and further victimization.

 

Sibling offender. Beyond responding to the sibling victim, participants also were concerned with responding to the needs of the sibling offender. Participants shared that there may be multiple victims of abuse, and all family mental health needs must be addressed. As school counselors, they “would be concerned on both ends” for the mental health needs and potential victimization of students who were both the victim and the offender of sibling abuse. Holly stated, “I assume if they [the sibling offender] are picking on this person, we are going to find out they are victims.” Margaret shared, “Whoever the perpetrator is, is struggling with something, either a mental illness or they were bullied or a victim of abuse themselves.” Grace described, “I would be fearful that that is coming from somewhere else, like violence between each other.”

 

Further victimization. Participants described their shared attitudes and beliefs that responding to sibling abuse without considering the needs of the sibling offender may result in the potential for further victimization, due to what participants described as a “trickle-down” effect. Ty stated, “You always pick on the next person down in the pecking order. It makes a lot of sense that she would go home and pick on the next one down.” Holly shared, “In reality, the perpetrators don’t think they did anything wrong and haven’t addressed it and worked through it.” Participants perceived that without intervention, sibling offenders might continue to victimize others and specifically mentioned cousins and peers as potential targets.

 

     Education and awareness. The fourth theme that emerged from the participant data was education and awareness. This theme was defined as participants’ shared attitudes and beliefs that an overall lack of awareness and education around the topic of sibling abuse has negatively influenced school counselors’ ability to respond to students. Participants shared that sibling abuse “does not come up a lot” and that there is an attitude of either “obliviousness or acceptance” around the topic of sibling abuse. In addition, this theme of education and awareness was further described as a potential contributing factor to the high rates of sibling abuse that might go unaddressed or unreported due to a lack of awareness or education. Based on these findings, this theme has been placed in both overarching categories. Three subthemes emerged from the participants’ descriptions of education and awareness—personal awareness and education, parental perceptions and societal norms, and educating students.

 

Personal awareness and education. For many participants, this study was the first time they had thought about sibling abuse, and all counselors shared that they had little to no training or education in this area. Lee shared, “It has been eye-opening to me to consider it because I have never given it any thought prior to this, so that in and of itself has been huge.” Margaret also mentioned being more aware after participating in this study, saying, “It is definitely something that is on my radar. . . . I am almost embarrassed to be naïve, but it never came up before.” Grace described, “It is something that I will look for more now when working with youth because I don’t think it was something that I thought much about before talking with you.”

 

     Parental perceptions and societal norms. Participants shared perceptions about students’ home lives and attributed the lack of awareness or education on the part of parents as a factor contributing to sibling abuse. Holly shared, “I think a lot of parents and other adults just think it is normal.” She further stated, “I don’t think they recognize when it goes too far. . . . I think it is awful to have a bully in the house that you are stuck with, and they should do everything they can to intervene.” Laura emphasized school counselors should be “focusing a lot on parenting skills and how we can help parents to learn things that would help.”

 

Educating students. Participants perceived that it is the school counselor’s role to educate students and provide them with support. Valerie stated that when it comes to sibling abuse, “Kids maybe have this misperception that ‘I should be able to handle this.’” Ty noted, “They [students] don’t even know they need help because it’s been going on so long. . . . It still makes me sad that most kids don’t realize it oftentimes until it is too late, and there will be permanent scars from it.” Laura added, “They don’t have an easy way to fix it or don’t know what to do if the sibling is a lot bigger and has a lot more power; naturally then you are kind of stuck.”

 

Factors Contributing to Sibling Abuse

     Sibling bond. The fifth theme that emerged from the participant data was sibling bond. This theme was defined as participants’ shared attitudes and beliefs about the importance of the sibling relationship and bond that exists between brothers and sisters. Participants noted the “powerfulness” of this sibling bond, which they believed might create an attachment as important as, or more important than, other family or peer relationships. Many participants discussed the influence of their own sibling relationships and shared that they thought “fondly” of their siblings and that therefore the sibling relationship should be “cherished and preserved at all costs.” School counselors’ belief that the sibling relationship should be preserved no matter what might interfere with their ability to recognize sibling abuse with students and therefore contribute to the problem. On the other hand, participants noted that this sibling bond also could create a sense of unhealthy “family loyalty,” which might lead to siblings becoming protective of one another to a fault. This protectiveness might contribute to the continuation of sibling abuse or violence due to fear that their “family is going to get torn apart” if reported. Two subthemes emerged from the participants’ descriptions of the sibling bond—preservation and perseverance, and family secrets.

 

     Preservation and perseverance. Many participants emphasized the importance of the sibling relationship within childhood development. Tiffany shared, “I think sibling relationships really define how people look at themselves and each other in the world, whether they realize it or not. . . . That is really how you have your first disagreements, your first shaming, your first happy moments.” Valerie shared, “I truly believe that the sibling relationships are powerful and they need to be cherished and preserved at all costs or improved.” Participants’ beliefs about the importance of preserving the sibling relationship influenced how they interacted with students, leading them to stress the importance of persevering when experiencing difficulty with a sibling. Ty mentioned that she had told students, “Right now you might be enemies, but you might be best friends when you are 22.”

 

     Family secrets. This subtheme related to participants’ perceptions about the strength of the sibling bond and how students might be keeping family secrets. Lee shared, “I think people don’t want to ‘dis’ their family. . . . Kids are reluctant to throw family members under the bus.” Ty stated that students are fearful of what might happen if they were to report. “They try to hide it so much. . . . I think there are all these rumors out there—‘I’m going to lose my family and I don’t want to be put in a foster home.’” Tiffany stated, “It really isn’t talked about; it is just lumped into ‘Oh, if anybody hurts you—but because it’s family it’s that loyalty piece and you can’t say anything.’”

 

     Learned violence. The sixth theme that emerged from the participant data was learned violence. This theme was defined as participants’ shared attitudes and beliefs about the ways in which children or adolescents might have come to learn that violence or abuse against a sibling is accepted or tolerated. The counselors shared that children often “do what they see” and that they “are so used to violence.” Participants concluded that sibling abuse was something students have learned from a variety of avenues contributing to the phenomenon. Four subthemes emerged from the participants’ descriptions of learned violence—intrafamilial violence, media and society, mental health, and gender and ethnicity.

 

     Intrafamilial violence. Other forms of violence within the home (parental, domestic) might support an environment where violence is learned, making it acceptable for siblings to be violent to one another. Grace questioned, “Is it because they have learned it from a parent or an aunt or an uncle or a grandparent?” Valerie shared, “Kids typically do what they see, what they are exposed to or what they experience. Either they are experiencing abuse or they see domestic violence.” Lee added, “In our population we are seeing more aggression and assertiveness in our parents, between parents, and when I think about the kids who have that tendency, that is what they are living with.”

 

     Media and society. Participants discussed that media and society portray violence as acceptable and that this permissiveness might influence children to be violent or abusive to their siblings. Laura shared, “I don’t know if it is the stress of what they are seeing and also the video games and other media that they have access to. Too often it’s not appropriate, so I think that can play a part, too.” Valerie shared, “They are exposed to video games, movies where aggression and violence is . . . acceptable human behavior.” Ty added, “We are so used to violence right now that wrestling or punching or slapping, we just say, ‘Oh, buck up, that wasn’t that big of a deal.’ A decade before we’d say, ‘That is not appropriate, that is not okay.’”

Mental health. Participants shared their perceptions that mental health needs or problems might contribute to sibling violence and abuse. One participant postulated that sibling offenders might be dealing with mental health issues in which they are more prone to anger. Grace shared, “I think it is something already within the kid. Are they born already with something inside of them?” Valerie stated, “I think it is possible that the kiddo that is doing most of the abuse has mental health problems like severe anxiety, depression or oppositional defiant disorder.” Margaret shared that children and adolescents might learn that violence is acceptable and carry this belief into relationships with their siblings. “There are underlying issues whether it be in the family or in the individual, whether it is depression or mental illness.”

 

Gender and ethnicity. Participants discussed in particular about how female students have learned that violence is acceptable. Ty noted that she worked with a diverse population of students from many different countries. She stated, “In many, many countries you can do what you want with women.” She posited that students learn about gender roles at home, saying, “Dad’s treating Mom that way; why shouldn’t I? I’ve been told not to put up [with] anything from a female.” Participants also observed that within certain ethnic groups, the acceptance of family violence varies. For example, Margaret worked at a school with many Asian students and noted that when it comes to discipline, “It has been interesting to learn cultural exceptions that it’s okay to hit their kids.” Ty mentioned, “Females in certain cultures . . . Hispanic [students] especially . . . I think they put up with a lot of crap and they don’t realize their worth. So I think they think they are open to being abused.”

 

     Systemic barriers. The seventh theme that emerged from the participant data was systemic barriers. This theme was defined as participants’ shared attitudes and beliefs about the systems that school counselors encounter as barriers to advocating for students experiencing sibling abuse. Although participants understood that it is their role to work with a variety of systems, such as CPS, law enforcement and families, they shared frustrations that there is “no follow-up” or that sibling abuse is “swept under the rug.” Participants reflected on the power dynamics that exist and the helplessness that they (as school counselors), the victim and even parents may experience due to systemic barriers. Many questioned who is responsible to respond and whether reports about sibling abuse would be taken seriously. Participants shared that the barriers they encounter in trying to get help for students experiencing maltreatment often contribute to the cycle of abuse. Although only three participants in this study had direct experience reporting sibling abuse in particular, all eight participants endorsed this theme and shared their attitudes and beliefs on trying to report abuse in general. The following two subthemes emerged from the participants’ descriptions of the systemic barriers: CPS and family systems.

 

Child protective services. Participants discussed the barriers in working with the CPS systems and other resources such as law enforcement. One of the barriers that participants repeatedly mentioned was little follow-up in helping students. Ty shared her frustration that representatives from social services would respond by saying, “We don’t have enough proof.” Margaret stated, “I have had one this week and one in the past where siblings have come to school with bruises from siblings. I did report it and the follow-up has not been really good from the social services agency.” Other participants shared that it was unclear whom they should be reporting sibling abuse to, and even social services and law enforcement seemed confused at times. Tiffany mentioned, “It gets passed off—‘Oh, well, it’s student to student; that’s a police thing’—sometimes the police don’t take it as seriously because it’s a family thing—‘Oh, well, contact the family’—and then it’s left in the family’s hands.”

 

Family systems. Related to this lack of clarity when reporting sibling abuse, participants also shared the difficulty they have encountered as school counselors when working with families to intervene for students experiencing sibling abuse. Lee stated, “If they can’t handle it themselves, they don’t want to reach out and ask for help or tell anybody because then the façade would be broken. I think that is maybe why it continues.” Many participants commented on how powerless children must feel to live in a home where parents allow sibling abuse to continue. Laura stated, “If the sibling is a lot bigger and has a lot more power, naturally then you are kind of stuck . . . no place to run to.” Holly added, “I think it’s very dangerous to have a sibling bully, abuser at home because you are trapped with them and often feel powerless to do something about that, and if parents aren’t responsive to your reporting them you’re just stuck.”

 

Discussion

 

Participants in this study shared that while they believe sibling abuse is most likely occurring with students in their schools, it is not something they often knowingly encounter. These findings are consistent with previous conclusions that sibling abuse is often unrecognized and therefore unaddressed (Button & Gealt, 2010; Eriksen & Jensen, 2006, 2009; Wiehe, 2002). At the time of data collection, only three of the eight counselors had directly worked with a student experiencing sibling abuse. Even among those participants, it was noted that reporting sibling abuse to school counselors is a rare occurrence. Participants agreed that it is plausible that sibling abuse occurs much more often than students, parents and school counselors recognize or report.

 

Throughout several themes, participants discussed shared beliefs that there is a climate of acceptance when it comes to sibling abuse, which contributes to the phenomenon. Participants shared that many counselors, themselves included, might have difficulty defining the line between normal sibling rivalry and sibling abuse. It was not surprising to discover that participants struggled to define sibling abuse, given that sibling abuse is often considered to be synonymous or interchangeable with terms such as sibling maltreatment, aggression and rivalry (Stutey & Clemens, 2015; Caffaro & Conn-Caffaro, 1998; Caspi, 2012; Hamel, 2007; Kettrey & Emery, 2006; Wiehe, 2002). In addition, participants believed that in some families, sibling violence or abuse might be misconstrued and amplified because of the presence of intrafamilial abuse.

 

Participants discussed their shared attitudes and beliefs about a variety of specific factors that might contribute to the acceptance of violence with siblings. The counselors shared their beliefs that children and adolescents might learn that violence and abuse are acceptable through their experiences at home, in the media, and society. They noted that students who are exposed to intrafamilial violence in the home often learn that violence is permissible. Many authors have found that the presence of intrafamilial violence in the home may increase the prevalence of violence between siblings (Caffaro & Conn-Caffaro, 1998; Caspi, 2012; Gelles & Cornell, 1985; Noland et al., 2004; Straus et al., 1980; Wallace, 2008; Wiehe, 2002).

 

Participants also shared a variety of attitudes related to their own feelings of powerlessness. Participants reported feeling frustrated when they encountered obstacles and barriers when trying to report sibling abuse or collaborate with parents and families. As previously discussed, school counselors are mandated child abuse reporters; yet this can be an ambiguous and challenging part of their job (Alvarez, Kenny, Donohue, & Carpin, 2004; Bae, Solomon, Gelles, & White, 2010; Bryant, 2009; Bryant & Baldwin, 2010; Hinkelman & Bruno, 2008; Remley & Fry, 1993). Given that resources to assist children being abused by adults may already be stretched thin, and that society tends to minimize the impact of sibling abuse, one can hypothesize that resources are even scarcer for victims of abuse by siblings. Participants shared feeling powerless to help students and posited concerns that students might also feel powerless.

Furthermore, participants discussed at length their concerns about not having received proper training to identify and intervene with students experiencing sibling abuse. Participants reported that a lack of preparation can be problematic in two ways. First, if they are unprepared as school counselors to recognize sibling abuse, this lack of preparation influences their ability to identify and address sibling abuse. Second, participants shared that if they are not informed, it is difficult to prepare their students, parents and faculty to recognize and report sibling abuse.

 

A final concept reiterated by participants was the influence of increased awareness about sibling abuse. As previously mentioned, sibling abuse is a topic seldom discussed or often excused as normal sibling rivalry (Caffaro & Conn-Caffaro, 1998; Caspi, 2012; Eriksen & Jensen, 2009; Wiehe, 2002). Participants shared that involvement in this study increased their awareness about sibling abuse. Increased awareness, in turn, influenced participants’ attitudes and beliefs about sibling abuse and the ways they plan to respond with students experiencing sibling abuse. By the end of the study, the counselors were inquisitive about ways they might increase the education and awareness of sibling abuse for others. School counselors working on behalf of and with students in the schools and at the public arena level are supported by both ASCA (2012) and the ACA advocacy competencies (Ratts & Hutchins, 2009).

 

Implications for Counseling

 

Several implications for counseling practice emerged based on the data provided by participants. First, the counselors emphasized the importance of providing training to increase education and awareness. Participants expressed how much they appreciated the story vignettes and Caspi’s (2012) sibling aggression continuum, which were utilized in the semistructured interviews. They suggested utilizing story vignettes and the sibling aggression continuum for professional development on the topic of sibling abuse. Wiehe (1997, 2002) provided multiple real-life scenarios from adult survivors of emotional, physical and sexual sibling abuse that may be effective in training counselors to identify the various forms of sibling abuse. Furthermore, practitioners might be able to utilize these same resources to holistically educate the clients with whom they work about sibling abuse, and to promote wellness.

 

Next, participants confirmed that sibling abuse is not a topic on educators’ radar. Encouraging and supporting collaboration between school counselors and other educators might provide opportunities for better awareness, identification and treatment of sibling abuse. Barrett, Lester, and Durham (2011) emphasized that school counselors are only one group of many responders advocating for children suffering from maltreatment in the school setting. They concluded that clinical mental health counselors, social workers, marriage and family therapists, and school psychologists should “all function as social justice advocates, especially in providing services to children who are underserved, disadvantaged, maltreated, or living in abusive situations” (Barrett et al., 2011, p. 87). Therefore, collaboration with other professionals within the school and community settings is one avenue that practicing school counselors might explore to ensure a holistic approach to promoting wellness and protecting children from harm.

Finally, while opportunities for training and collaboration with community resources are two implications for practice, participants also stressed the importance of establishing policies for reporting sibling abuse. One avenue that school counselors can use to respond to sibling abuse is social justice advocacy. Practicing school counselors and counselor educators may need to advocate for changes in district, state and federal laws and policies. The ACA has endorsed that all counselors should meet advocacy competencies in their work with clients. Furthermore, “social justice is a key task of the 21st-century, professional school counselor” (Ratts et al., 2007, p. 90). Applying a social justice-inspired advocacy lens when working with students experiencing sibling abuse might allow school counselors to advocate at the individual, school and public arena levels.

 

Based on the findings of this research, the topic of social justice advocacy also has implications for counselor educators and supervisors. Constantine, Hage, Kindaichi, and Bryant (2007) shared that education with master’s students at the public arena level might require modifications to current curriculum, writing, “To prepare future counselors. . . to assume social justice roles, it is vital that the structure, requirements, and goals of many graduate training programs are modified to assist students in developing competencies to intervene at broader levels” (p. 27). Counselors-in-training must receive the proper education on their role and responsibility as practitioners and social justice-inspired advocates at all three levels.

 

Future Research

 

The results of this study present the need for future research about sibling abuse, especially within the school counseling field. First, research could be conducted to learn whether existing programs and trainings on child abuse might also be effective to work with students experiencing sibling abuse. Participants suggested that perhaps anti-bullying curricula that examine peer-to-peer violence also might be helpful in addressing sibling abuse. Second, research on effective ways to identify and respond to sibling abuse is imperative in order to inform practicing school counselors, and other counseling practitioners, on ways in which to intervene and treat sibling abuse in the school setting. In addition, studies on effective ways to identify and respond to sibling abuse could be replicated with clinical mental health and marriage, couple and family counselors working in community settings. Finally, there are opportunities for future research in the counselor education and supervision field. Insight into the education and awareness of counselor educators and their beliefs and attitudes about sibling abuse might be an initial point of entry. This research could be expanded to examine whether and how counselor educators train counselors—in particular, school counselors—on ways to define, identify and intervene with clients or students experiencing sibling abuse.

 

Conflict of Interest and Funding Disclosure

The authors reported partial funding for the

research study by Graham Fund Grant.

 

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Diane M. Stutey, NCC, is a Lecturer at Clemson University. Correspondence may be addressed to Diane M. Stutey, 322 Tillman Hall, Clemson, SC 29634, dstutey@clemson.edu.

The author expresses her deepest gratitude to Dr. Jennifer Murdock and Dr. Heather Helm for guiding her through the dissertation research process while she was a doctoral candidate at the University of Northern Colorado, and those who willingly participated in this study. In addition, special thanks to the Graham Fund Grant that partially funded this research study.

 

Technology in Counselor Education: HIPAA and HITECH as Best Practice

Tyler Wilkinson, Rob Reinhardt

The use of technology in counseling is expanding. Ethical use of technology in counseling practice is now a stand-alone section in the 2014 American Counseling Association Code of Ethics. The Health Insurance Portability and Accountability Act (HIPAA) and the Health Information Technology for Economic and Clinical Health (HITECH) Act provide a framework for best practices that counselor educators can utilize when incorporating the use of technology into counselor education programs. This article discusses recommended guidelines, standards, and regulations of HIPAA and HITECH that can provide a framework through which counselor educators can work to design policies and procedures to guide the ethical use of technology in programs that prepare and train future counselors.

Keywords: counselor education, technology, best practice, HIPAA, HITECH

The enactment of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) brought forth a variety of standards addressing the privacy, security and transaction of individual protected health information (PHI; Wheeler & Bertram, 2012). According to the language of HIPAA (2013, §160.103), PHI is defined as “individually identifiable health information” (p. 983) that is transmitted by or maintained in electronic media or any other medium, with the exception of educational or employment records. “Individually identifiable health information” is specified as follows:

 

Information, including demographic data, that relates to:

  • the individual’s past, present or future physical or mental health or condition,
  • the provision of health care to the individual, or
  • the past, present, or future payment for the provision of health care to the individual, and that identifies the individual for which there is a reasonable basis to believe can be used to identify the individual. Individually identifiable health information includes many common identifiers. (U.S. Department of Health and Human Services [HHS], n.d.-b, p. 4)

The HIPAA standards identify 18 different elements that are considered to be part of one’s PHI. These include basic demographic data such as names, street addresses, elements of dates (e.g., birth dates, admission dates, discharge dates) and phone numbers. It also includes information such as vehicle identifiers, Internet protocol address numbers, biometric identifiers and photographic images (HIPAA, 2013, § 164.514, b.2.i).

According to language in HIPAA, the applicability of its standards, requirements and implementation only apply to “covered entities,” which are “(1) a health plan (2) a health care clearinghouse (3) a health care provider who transmits any health information in electronic form in connection with [HIPAA standards and policies]” (HIPAA, 2013, § 160.102). Covered entities have an array of required and suggested privacy and security measures that they must take into consideration in order to protect individuals’ PHI; failure to protect individuals’ information could result in serious fines. For example, one recent ruling found a university medical training clinic to be in violation of HIPAA statutes when network firewall protection had been disabled. The oversight resulted in a $400,000 penalty (Yu, 2013). Moreover, the recent implementation of the Health Information Technology for Economic and Clinical Health (HITECH) Act in 2009 increased the fines resulting from failure to comply with HIPAA, including fines for individuals claiming they “did not know” that can range from $100–$50,000 (Modifications to the HIPAA Privacy, 2013, p. 5583). The final omnibus ruling of HIPAA–HITECH, enforcing these violations, went into effect on March 26, 2013 (Modifications to the HIPAA Privacy, 2013; Ostrowski, 2014). Enforcement of the changes from the HITECH Act on HIPAA standards began on September 23, 2013, for covered entities (Modifications to the HIPAA Privacy, 2013).

 

Academic departments and universities must understand the importance of HIPAA and HITECH regulations in order to determine whether the department or university is considered a covered entity. Risk analysis and management need to be employed to avoid violations leading to penalties and fines (HIPAA, 2013, §164.308). Some counselor education programs that have students at medically related practicum or internship sites also may be considered business associates (see HIPAA, 2013, § 160.103) and would need to comply with HIPAA regulations (see HIPAA, 2013, § 160.105). The authors recommend that all counselor education programs confer with appropriate legal sources to understand any risks or liabilities related to HIPAA regulations and relationships with practicum and internship sites. Many states also have their own unique privacy laws that must be considered in addition to those described in HIPAA regulations. The purpose of this article assumes that a counselor education department is not considered a covered entity by the regulations set forth by HIPAA. However, as an increasing number of counselor education programs incorporate the use of digital videos or digital audio recordings, a need for a set of policies and procedures to guide the appropriate use of digital media is evident.

 

The authors believe that the regulations set forth by HIPAA and HITECH create a series of guidelines that could dictate best practices for counselor educators when considering how to utilize technology in the collection, storage and transmission of any individual’s electronic PHI (Wheeler & Bertram, 2012) within counselor education programs. HIPAA regulations (2013, §160.103) describe electronic protected health information (ePHI) as any information classified as PHI, as described above, either “maintained by” or “transmitted in” (p. 983) electronic media. For example, audio recordings used in practicum and internship courses are often collected electronically by digital recorders. If the recordings remain on the device, this protected information is being maintained in an electronic format. If the data is shared through e-mail or uploaded to a computer, then it is being transmitted in electronic format. As it relates to counselor training, the PHI that is collected could be real or fictitious (i.e., from someone role playing in the program). Though fictitious information is not necessarily protected, encouraging students to engage in implementing a set of policies and procedures guided by regulations of HIPAA and HITECH creates an experiential milieu whereby students become aware of and learn the importance of security and privacy when handling digital ePHI. The authors will discuss throughout this article how specific regulations from HIPAA and HITECH can be utilized to create a set of policies and procedures that guide the ways in which members of counselor education programs can handle any ePHI they encounter during their training. These direct experiences will give faculty and students greater familiarity with current HIPAA and HITECH regulations, thus making them better prepared to work ethically and legally in modern mental health culture.

 

This article is not meant to cover HIPAA and HITECH regulations in a comprehensive manner. Overviews of these standards have been written concerning the regulations of HIPAA and HITECH regarding the work of mental health practitioners (see Letzring & Snow, 2011). The degree to which the myriad regulations of HIPAA will be implemented in various counselor education programs will need to be decided by the members of individual programs and by necessary stakeholders. The authors hope to introduce a dialogue regarding the thoughtful use of technology in counselor education programs guided by the parameters set forth by HIPAA.

 

According to the Substance Abuse and Mental Health Services Administration (SAMHSA; 2013), the trend in mental health care treatment spending is in the direction of public (i.e., Medicare and Medicaid) and private insurance growth as a means of payment. Spending for all mental health and substance abuse services totaled $172 billion in 2009; moreover, this spending accounted for 7.4% of all health care spending that year. Additionally, it is projected that spending on all mental health and substance abuse services could reach $238 billion by 2020 (SAMHSA, 2014). However, the rate at which individuals pay out-of-pocket for mental health and substance abuse services is expected to decrease steadily (SAMHSA, 2014). Historical trends show out-of-pocket spending decreased from 18% of all spending in 1986 to 11% in 2009 (SAMHSA, 2013, 2014). It is projected that out-of-pocket spending for mental health treatment will level off to account for approximately 10% of all spending while Medicaid, Medicare, and private insurance will account for approximately 70% of spending (SAMHSA, 2014). The trend toward greater insurance use will increase the number of professional counselors who will be seen as or will be working within organizations that are considered HIPAA-covered entities. Implementing policies and procedures in counseling departments that incorporate some of the HIPAA regulations is a useful way to prepare future professionals for the working environment they will enter (SAMHSA, 2013).

 

The implementation of the HITECH Act (2009) as a supplement to HIPAA emphasized the need to make sure future counselors understand the importance of the increasing role of technology in the practice of counseling (Lawley, 2012). The HITECH Act established an expectation that professionals in health care must be familiar with technology, specifically as it relates to policies guiding the storage and transmission of ePHI. The objectives of HITECH include “the electronic exchange and use of health information and the enterprise integration of such information” and “the utilization of an electronic health record for each person in the United States by 2014” (HITECH, 2009, §3001.c.A, emphasis added). Additionally, HITECH strengthened the enforcement of penalties for those who violate HIPAA (Modifications to the HIPAA Privacy, 2013). A multi-tiered system of violations allows for civil money penalties to range from $100–$50,000 per violation (Modifications to the HIPAA Privacy, 2013). The American Counseling Association’s (ACA) 2014 Code of Ethics acknowledged the increasing use of technology by professional counselors by introducing a new section (Section H) addressing the ethical responsibility of counselors to understand proper laws, statutes, and uses of technology and digital media. Ethical counselors are expected to understand the laws and statutes (H.1.b), the uniqueness of confidentiality (H.2.b), and the proper use of security (H.2.d) regarding the use of technology and digital media in their counseling practice.

 

The mental health care system exists inside the broader health care system. As such, graduates of counseling programs must be familiar with HIPAA regulations and the various modes of technology to implement these regulations (ACA, 2014; Lawley, 2012). Students will be expected to understand what security and privacy standards are required of them once they begin working as counseling professionals (ACA, 2014). For example, the movement toward increased use of ePHI across health care will place increasing demands on students to understand how to appropriately keep electronic data private and secure. Counselor educators need to be mindful of how the use of technology in the practice of counseling is being taught and implemented with counseling students. Counselor educators should thoughtfully consider how students will learn the ways in which technology can be used professionally while maintaining ethical and legal integrity (Association for Counselor Education and Supervision [ACES] Technology Interest Network, 2007; Wheeler & Bertram, 2012). Having standards to guide the use of ePHI throughout counselor education programs is a way in which students can become knowledgeable and skilled regarding the laws and ethics surrounding digital media. Policies and procedures should include information guiding the ways in which students collect, store and transmit digital media (e.g., audio recordings or videotapes) while a member of the counseling program. By requiring students to utilize the ePHI (real or fictitious) they collect in accordance with policies and procedures informed by HIPAA and HITECH, students crystallize their understanding of these complicated laws.

 

HIPAA Compliance and Technology

 

Complying with HIPAA Privacy and Security Rules requires individuals to be mindful of policies and procedures, known as “administrative safeguards” (HIPAA, 2013, §164.308, p. 1029), and work to implement safeguards consistently. The HHS has made clear that it does not provide any type of credential to certify that an individual, business, software or device is HIPAA compliant (HHS, n.d.-a; Reinhardt, 2013). Complying with HIPAA rules requires organizations and individuals to address many different processes where choice of hardware or software is only one aspect (Christiansen, 2000). Being HIPAA compliant is less about a certification or a credential on a device and more about having a set of policies and procedures in place that ensure the integrity, availability and confidentiality of clients’ ePHI (Christiansen, 2000; HHS, n.d.-b). Hardware and software technology companies who make claims that a product or an educational resource is HIPAA compliant are likely doing so for marketing purposes. Claims of this type are mostly meaningless (HHS, n.d.-a) and would not provide protection in the case of a breach (HITECH, 2009). Being HIPAA compliant is an “organizational obligation not a technical specification” (Christiansen, 2000, p. 7). The distinction is important for educators to understand as they seek to implement technology in counselor education programs. When establishing a set of policies and procedures within a counseling department, the recommendations set forth in describing the security and privacy of PHI in Part 164 of HIPAA (2013) can be an appropriate framework for establishing best practices for counselors and counselor educators. The general requirements in complying with HIPAA security standards are to ensure the confidentiality, integrity and availability of individuals’ ePHI while protecting against any reasonably anticipated threats to the security and privacy of said ePHI (HIPAA, 2013, §164.306.a). The key phrase to consider is that covered entities are asked to protect against any “reasonably anticipated” (HIPAA, 2013, §164.306.a, p.1028) threat. Educators must understand the importance of spending time considering reasonable, foreseeable risks. A primary responsibility is to create administrative safeguards that address any reasonable, foreseeable risks, which the individual, department or covered entity establishes.

 

Before looking at key aspects of HIPAA Privacy and Security guidelines, key definitions should be understood:

 

  • Administrative safeguards include policies and procedures used to manage the development, selection, implementation and security in protecting individuals’ ePHI (HIPAA, 2013, § 164.304).
  • Authentication includes “the corroboration that a person is the one claimed” (HIPAA, 2013, § 164.304, p. 1027).
  • Confidentiality defines “the property that data or information is not made available or disclosed to unauthorized persons or processes” (HIPAA, 2013, § 164.304, p. 1027).
  • Encryption is “the use of an algorithmic process to transform data into a form in which there is a low probability of assigning meaning without the use of a confidential process or key” (HIPAA, 2013, § 164.304, p. 1027).
  • Security incident is described as “the attempted or successful unauthorized access, use, disclosure, modification, or destruction of information or interference with system operation in an information system” (HIPAA, 2013, § 164.304, p. 1027).

 

HIPAA (2013) standards are categorized as either required or addressable as indicated in Section 164.306.d.1. The rest of this document will highlight the standards that the authors believe shape a set of best practices for counselor educators when implementing technology into their counselor education programs. The degree to which a counseling program decides to implement those standards that are considered required or addressable will be determined by their status as a covered entity, state laws, needs of their counseling program and the financial feasibility of implementing these standards.

 

Safeguards

 

     HIPAA requires that all covered entities maintain policies and procedures that (1) ensure confidentiality and availability of all electronic PHI, (2) protect against any reasonably (emphasis added) anticipated threats or hazards to the security or integrity of ePHI, (3) protect against any reasonably anticipated uses or disclosures of ePHI, and (4) ensure compliance by the workforce. The following sections will discuss ways in which HIPAA Privacy and Security rules can be utilized as best practices in counselor education programs so that foreseeable risks, threats and vulnerabilities may be minimized. Please note that this interpretation of safeguards is intended for the consideration of counselor education programs that are not covered entities, but may use HIPAA Privacy and Security rules to establish a set of policies and procedures as a means of best practice. (For a sample guide for counselor educators to use in developing policies and procedures, please contact the first author).

 

Administrative Safeguards

Administrative actions and oversight make up an important component of the language within HIPAA (2013). Administrative safeguards consist of the policies and procedures designed to “manage the selection, development, [and] implementation” (§ 164.304, p. 1027) of the security and privacy of one’s ePHI. This section describes HIPAA standards to consider when establishing administrative safeguards.

 

Assigned responsibility. A faculty or staff member within the counselor education program should be identified as responsible for the development, oversight and implementation of the policies and procedures for the department. The faculty member needs to be familiar with the privacy and security policies of HIPAA in order to implement the policies and procedures and to facilitate student training in ways that address the specific needs of the program. Developing a relationship with a staff member in the university information technology department may result in collaborative efforts regarding specific procedures for the use of technology within the university.

 

     Risk analysis. Before counselor educators can design a set of policies and procedures to guide appropriate technology use, the foreseeable risks must be analyzed. An accurate and thorough assessment is needed to identify potential risks to the protection and security of ePHI (HIPAA, 2013, §164.308) that is collected, stored and transmitted in the counseling program. Analyzing potential risk is essential to the minimization of potential disasters in the future (Dooling, 2013). HHS (2007) makes clear that it is important to spend time considering reasonably anticipated threats and vulnerabilities and then to implement policies and procedures to address the assessed risks. HIPAA security standards do not state that covered entities should protect against all possibly conceived threats, but those that can be “reasonably anticipated” based upon the technologies employed, work environments and employees of the covered entity. The National Institute of Standards and Technology (NIST; 2012) defines a threat “as any circumstance or event . . . with the potential to adversely impact organization operations . . . through an information system via unauthorized access, destruction, disclosure, or modification of information” (p. B-13). A risk is a measure of the probability of a threat triggering a vulnerability in the procedures that an organization uses to ensure the privacy and security of ePHI (NIST, 2012). Vulnerabilities are technical and non-technical weaknesses, which include limitations in utilized technology or ineffective policies within the organization (HHS, 2007). In counselor education programs, risk analysis may include looking at the threats and vulnerabilities associated with counseling students traveling between their residence, campus, and practicum or internship sites while carrying ePHI. Moreover, the analysis must include assessing the potential risks associated with the transmission and storage of protected information using technological media (e.g., e-mail, personal computers, cloud-based storage, external storage devices).

 

Risk management. Risk management is the ongoing process of implementing measures to reduce the threats that were determined as a part of the risk analysis (HHS, 2007). Once a counseling program has assessed and identified potential risks associated with the collection, transmission and storage of any identifiable information, it must begin to manage these risks. HHS has provided an example list of steps to assist organizations in conducting risk analysis and risk management (see Table 1). Members of counselor education programs can begin to incorporate programmatic policies and procedures that address how media containing ePHI should be handled by members of the program. The previously mentioned document (available from the first author) provides sample policies and procedures developed to serve as a guide for counseling programs. Many counselor education programs utilize student handbooks that detail policies related to the academic and professional expectations of students enrolled in their program. Incorporating an additional set of policies to address the treatment of ePHI is a seamless way to begin managing the risks of technology use in mental health. By implementing policies and procedures across the curriculum, students become increasingly knowledgeable and skilled at handling ePHI in an ethical manner.


Table 1

 

Example Risk Analysis and Risk Management Steps

Risk Analysis

1. Identify the scope of the analysis.
2. Gather data.
3. Identify and document potential threats and vulnerabilities.
4. Assess current security measures.
5. Determine likelihood of threat occurring.
6. Determine potential impact of threat occurrence.
7. Determine level of risk.
8. Identify security measures and finalize documentation.

Risk Management

1. Develop and implement a risk management plan.
2. Implement security measures.
3. Evaluate and maintain security measures.

Note. Adapted from “Basics of Risk Analysis and Risk Assessment,” by the U.S.
Department of Health and Human Services, 2007, HIPAA Security Series, 2(6), p. 5.

 

Sanction policy. It must be communicated to all members of counselor education programs that failure to comply with the policies will result in sanctions. HIPAA (§164.308, 2013) requires organizations to enforce sanctions against individual members for failing to comply with their organization’s policies and procedures. A counselor education program should have clearly documented policies and procedures for students and staff involved with the facilitation of ePHI. The language of HIPAA makes no attempt to clarify as to what these sanctions should entail; however, language needs to exist that addresses individuals’ failure to comply. For counseling students, a potential option is to consider a tiered sanction policy similar to that of the structure established by the HITECH Act (Modifications to the HIPAA Privacy, 2013) and § 1176 of the Social Security Act (2013). Varying categories of violations from “did not know” (p. 5583) to uncorrected–willful neglect result in increasingly severe fines (Modifications to the HIPAA Privacy, 2013). Since this experience is most likely educational for students, varying degrees of failure to comply could exist. For counselor education programs, this language also could easily be tied to student remediation processes that many counseling programs utilize.

 

Information review. Ongoing review of the activity of students, faculty and staff that involves the creation, storage and transmission of ePHI is a required safeguard according to HIPAA standards (2013, §164.308). As an educational unit, it is understandable that individuals might make mistakes regarding the implementation of HIPAA safeguards. A regular review of the activity and records of the individuals whose ePHI are being collected is important. It is required for organizations to have policies in place for recording system activity, including access logs and incident reports (§ 164.308). Additionally, protections must be in place to ensure that only those individuals who should have access to any ePHI are able to access this protected information. In the case of the sanctioned university medical training clinic cited earlier, the breaches might have been avoided with an ongoing review of the system’s firewall settings (Yu, 2013). Monitoring and developing policies regarding information review may require developing relationships and discussions with the appropriate information technology personnel at the organization.

 

Response, recovery and reporting plan. HIPAA regulations require that a covered entity have a plan in place should ePHI be breached or disclosed to an unauthorized party (HIPAA, 2013, § 164.308). When developing departmental policies and procedures, it is important to have such a plan in place. Whether the breach or disclosure is intentional or unintentional, each individual whose information has potentially been compromised needs to be notified. Moreover, in cases where more than 500 individuals’ PHI have been breached, the entity may need to report this information to local media or to HHS (HIPAA, 2013, §164.406–164.408). It should be noted that covered entities could be exempted from breach notification through employing security techniques such as encryption (Breach Notification, 2009; HIPAA, 2013, §164.314). The regulations of HIPAA require that a plan be in place to address emergencies (HIPAA, 2013, §164.308). In the case of theft, emergency or disaster, counseling departments need a data backup and recovery plan in place to retrieve ePHI.

 

Physical Safeguards

     Establishing policies and procedures that protect against unauthorized physical access and damage from natural or environmental hazards is critical to maintaining the security and privacy of PHI (HIPAA, 2013, §164.310).

 

     Access control. When using technology to store and transmit ePHI, the recommendation is that policies address ways in which physical access to protected information will be limited. For example, many counseling departments now incorporate the use of digitally recorded data from counseling sessions (e.g., audio or video). Policies need to clearly address how to best limit physical access to these recordings. Students need to understand what it means to keep data physically secure. The HITECH Act (Modifications to the HIPAA Privacy, 2013) includes the category “did not know” as a punishable violation. Students need to understand the consequences of failing to implement such physical safeguards. For example, keeping devices stored under lock and key when not in use is just one important step in moving toward a set of best practices. Many universities already require students to utilize login information with a username and passcode in order to access computers affiliated with their respective university. Consideration may need to be given regarding policies and procedures for accessing ePHI off campus, where the technical security may be less controlled.

 

Disposal and re-use. HIPAA requires covered entities to implement policies that address the disposal and re-use of ePHI on electronic media. A detailed discussion of the various types of disposal, also known as media sanitization, and re-use is beyond the scope of this article (see Kissel, Regenscheid, Scholl, & Stine, 2014). Counselor education programs must recognize the importance of properly removing protected information from media devices after it is no longer required. Media sanitization is a critical element in assuring confidentiality of information (Kissel et al., 2014). For example, in counseling internship courses, students may be asked to delete recorded sessions during the last day of classes so that the instructor can have evidence of the appropriate disposal of this information. NIST identifies four different types of media sanitization: disposal, clearing, purging and destroying (Kissel et al., 2014). The decision as to which type of media sanitization is appropriate requires a cost/benefit analysis, as well as an understanding of the available means to conduct each type of sanitization. (The authors recommend counseling departments consult with an individual from the university information technology department).

 

Technical Safeguards

The language in HIPAA is clear regarding the implementation of technical safeguards, requiring that access to electronic media devices containing PHI be granted only to those who need such access to perform their duties.

 

     Unique user identification. If a device allows for unique user identification, one should be assigned to minimize the unintended access of ePHI. HIPAA standards (2013, §164.514) state that an assigned code should not be “derived from or related to information about the individual” (p. 1064).

 

     Emergency access. Covered entities are required to have procedures in place that allow ePHI to be accessed in the event of an emergency (HIPAA, 2013, §164.310). The procedures can be addressed within counselor education programs so as to ensure that the student and the supervisor have access to the ePHI at the designated storage location.

 

     Encryption. Encryption is a digital means of increasing the security of electronic data. Using an algorithmic process, the data is scrambled so that the probability of interpretation is minimal without the use of a confidential key to decode the information. Though the language of HIPAA categorizes encryption as addressable rather than required, the implementation of encryption policies is a best practice to help ensure the protection of ePHI. The language of HIPAA makes it clear that an “addressable” item must be implemented if it is “reasonable and appropriate” (HIPAA, 2013, §164.306, p. 1028) to do so. Huggins (2013) has recommended that ePHI be stored on drives that allow for “full disk encryption” at a minimum strength of 128 bits. With the availability of many different types of software packages that can encrypt at a recommended strength, implementing encryption standards in a counseling department is affordable and reasonable. Most modern computer operating systems have options to encrypt various drives built into the functionality of the system. Full disk encryption is recommended because of its higher level of security and also because it can provide exemption from the Breach Notification Rule mentioned earlier (Breach Notification, 2009). In case of a breach, the burden is on the covered entity to prove that the ePHI was not accessed; otherwise, Breach Notification Rules must be followed. The assumption is that if a disk is fully encrypted, even if accessed by an unauthorized person, it is highly unlikely that an unauthorized party will obtain access to the ePHI (Breach Notification, 2009). The authors strongly encourage the use of encrypted devices as a standard policy for the collection and storage of ePHI (see Scarfone, Souppaya, & Sexton, 2007). The policy creates greater protection against the accidental disclosure of an individual’s ePHI. Additionally, organizations that use commercial cloud storage service providers should investigate whether these providers are willing to sign a Business Associate Agreement, in which the provider agrees to adhere to regulations of HIPAA (2013, §160.103). If not, the storage of ePHI may not be in alignment with HIPAA standards.

 

Disk encryption works well for the storage and collection of protected information while at rest (Scarfone et al., 2007); however, counselor education programs also should consider assessing the risk associated with the transmission of ePHI (HIPAA, 2013, §164.312). Protected information often remains encrypted while at rest, yet becomes unencrypted while in transmission. Programs need to “guard against unauthorized access to electronic PHI that is being transmitted over an electronic communication network” (HIPAA, 2013, §164.312, p. 1032). Commonly used e-mail systems, for example, often do not transmit information in an encrypted state. Assessment of the risks in sending protected information by an unsecured means should be conducted.

 

Discussion

 

     The language of HIPAA allows each covered entity some leeway in how it wants to implement policies. However, HIPAA standards (2013, §164.316) are very clear that entities should “implement reasonable and appropriate policies”(p. 1033) that include administrative, physical and technical safeguards that reasonably and appropriately protect the confidentiality, integrity and availability of electronic PHI that it creates, receives, maintains or transmits. The implementation of HITECH (2009) and the meaningful use policies of the Affordable Care Act (Medicare and Medicaid Programs, 2014) emphasized the movement of the broader health care system toward increasing use of health care technology such as Electronic Health Records. Students graduating from counseling programs find themselves working in myriad settings, many of which are considered covered entities as defined in the HIPAA standards (2013, §160.103). It is imperative for counselor educators to recognize the trend toward increased technology use in the health care market and to consider ways that technology can be infused into counselor education so that students are entering the workforce with greater technological competence. Specifically, counselor educators have an imperative to teach the ethical and legal technological mandates that exist as they relate to regulations of HIPAA (2013) and HITECH (2009) so as to create competent counselors. As the health care industry continues to incorporate more technology, counselor educators must stay informed regarding ways in which graduates will utilize this technology in their professional careers.

 

Recommendations for Counselor Educators

     ACES (2007) published a document that recommends guidelines for infusing technology into counselor education curriculum, research and evaluation. This document provides a basic overview by which programs should guide the very broad use of technology in counseling programs. Technology is presented as a useful enhancement or supplement to practice. The shift in the broader health care culture has moved technology from a supplementary role into one in which it is primary to the ongoing success of a practitioner. The authors believe that counselor educators can utilize HIPAA and HITECH regulations to continue to infuse technology into counselor education programs, and recommend the following:

 

  1. Counselor educators need to increase the importance placed on technology in counselor education programs. The movement of technology into increasingly primary roles in health care is indicative of the need for it to become a primary focus during the education and training of counselors. Counselors and counselor educators must stay abreast of the trends and developments regarding health care law and technology. The implementation of Section H, “Distance Counseling, Technology, and Social Media,” in the 2014 ACA Code of Ethics also is indicative of this need. The counseling profession needs to increase the research, education and training available to counselors and counselor educators.

 

  1. Counselor educators need to have policies and procedures in place guiding the use of technology in their departments. The overview of HIPAA regulations will help provide guidelines for developing a set of policies and procedures. All policies and procedures must be in writing and accessible to students, faculty and staff who have access to any ePHI. Many counseling programs maintain a student handbook in which a set of standards that dictate the use of technology could easily be incorporated. Departmental policies should be in place that dictate the consequences should an individual fail to adhere to the stated policies and procedures.

 

  1. Counselor educators should be actively seeking ways in which technology and HIPAA can be incorporated to best prepare students for their future work environment. The regulations and language of HIPAA and HITECH should be addressed in course activities. Are counseling students getting opportunities to become familiar with Electronic Health Records? Are students having opportunities to write and store notes electronically? Have students addressed the ethical and legal concerns related to the use of technology in practice? Do students understand what it means to maintain encrypted files or how to appropriately de-identify ePHI? Do students understand how to submit health insurance claims electronically? Questions like these are necessary for students to understand so they can be prepared to work in the current mental health environment as competent professionals.

 

The use of technology in counseling is moving from a secondary to a primary place in counselor education. The expectation that students can find this information after graduation in the form of a workshop is no longer acceptable. The shifts in the language of HIPAA and HITECH have moved the broad health care field in an electronic, digital direction. The familiarity with technology seems to be growing toward a core competency of counselor education programs and faculty. The laws dictated by HIPAA and HITECH provide a framework by which counselor educators can continue to infuse technology into the classroom and clinical experiences.

 

 

Conflict of Interest and Funding Disclosure

The authors reported no conflict of interest

or funding contributions for the development

of this manuscript.

 

References

 

American Counseling Association. (2014). ACA code of ethics. Alexandria, VA: Author.

Association for Counselor Education and Supervision Technology Interest Network. (2007). Technical competencies for counselor education: Recommended guidelines for program development. Retrieved from http://www.acesonline.net/sites/default/files/2007_aces_technology_competencies.pdf

Breach Notification for Unsecured Protected Health Information, 74 Fed. Reg. 162 (August 24, 2009) (to be codified at 45 CFR §§ 160 & 164).

Christiansen, J. (2000). Can you really get “HIPAA Compliant” software and devices? IT Health Care Strategist, 2(12), 1, 7–8.

Dooling, J. A. (2013). It is always time to prepare for disaster. Journal of Health Care Compliance, 15(6), 55–56.

Health Information Technology for Economic and Clinical Health (HITECH) Act, Title XIII § 13001 of Division A of the American Recovery and Reinvestment Act of 2009 (AARA), Pub. L. No. 111-5 (2009).

Health Insurance Portability and Accountability Act (HIPAA), 45 CFR §§ 160, 162, & 164 (2013). Retrieved from http://www.gpo.gov/fdsys/pkg/CFR-2013-title45-vol1/pdf/CFR-2013-title45-vol1-chapA-subchapC.pdf

Huggins, R. (2013, April 5). HIPAA “safe harbor” for your computer (the ultimate in HIPAA compliance): The compleat [sic] guide [Blog post]. Retrieved from http://www.personcenteredtech.com/2013/04/hipaa-safe-harbor-for-your-computer-the-ultimate-in-hipaa-compliance-the-compleat-guide/

Kissel, R., Regenscheid, A. Scholl, M., & Stine, K. (2014). Guidelines for media sanitization (NIST Publication No. 800-88, Rev. 1). Retrieved from http://nvlpubs.nist.gov/nistpubs/SpecialPublications/NIST.SP.800-88r1.pdf

Lawley, J. S. (2012). HIPAA, HITECH and the practicing counselor: Electronic records and practice guidelines. The Professional Counselor, 2, 192–200. doi:10.15241/jsl.2.3.192

Letzring, T. D., & Snow, M. S. (2011). Mental health practitioners and HIPAA. International Journal of Play Therapy, 20, 153–164. doi:10.1037/a0023717

Medicare and Medicaid Programs; Modifications to the Medicare and Medicaid Electronic Health Record (EHR) Incentive Program for 2014 and Other Changes to the EHR Incentive Program; and Health Information Technology: Revisions to the Certified EHR Technology Definition and EHR Certification Changes Related to Standards Final Rule, 79 Fed. Reg., 179 (September 4, 2014) (to be codified at 45 CFR pt. 170).

Modifications to the HIPAA Privacy, Security, Enforcement, and Breach Notification Rules Under the Health Information Technology for Economic and Clinical Health Act and the Genetic Information Nondiscrimination Act; Other Modifications to the HIPAA Rules; Final Rule, 78 Fed. Reg., 5566 (January 25, 2013) (to be codified at 45 CFR pts. 160 and 164).

National Institute of Standards and Technology. (2012). Guide for conducting risk assessments (NIST Special Publication No. 800-30, Rev. 1). Retrieved from http://csrc.nist.gov/publications/nistpubs/800-30-rev1/sp800_30_r1.pdf

Ostrowski, J. (2014). HIPAA compliance: What you need to know about the new HIPAA-HITECH rules. Retrieved from http://www.nbcc.org/assets/HIPAA_Compliance.pdf

Reinhardt, R. (2013, October 3). Your software and devices are not HIPAA compliant [Blog post]. Retrieved from http://www.tameyourpractice.com/blog/your-software-and-devices-are-not-hipaa-compliant

Scarfone, K., Souppaya, M., & Sexton, M. (2007). Guide to storage encryption technologies for end user devices: Recommendations of the national institute of standards and technology (NIST Special Publication No. 800-111). Retrieved from http://csrc.nist.gov/publications/nistpubs/800-111/SP800-111.pdf

Social Security Act, 42 U.S.C. § 1176 (a)(1). (2013). Retrieved from http://www.ssa.gov/OP_Home/ssact/title11/1176.htm

Substance Abuse and Mental Health Services Administration. (2013). National expenditures for mental health services & substance abuse treatment, 1986–2009 (HHS Publication No. SMA-13-4740). Retrieved from http://store.samhsa.gov/shin/content//SMA13-4740/SMA13-4740.pdf

Substance Abuse and Mental Health Services Administration. (2014). Projections of national expenditures for treatment of mental and substance use disorders, 2010–2020 (HHS Publication No. SMA-14-4883). Retrieved from http://store.samhsa.gov/shin/content//SMA14-4883/SMA14-4883.pdf

U.S. Department of Health and Human Services. (n.d.-a). Be aware of misleading marketing claims. Retrieved from http://www.hhs.gov/ocr/privacy/hipaa/understanding/coveredentities/misleadingmarketing.html

U.S. Department of Health and Human Services. (n.d.-b). Summary of the HIPAA privacy rule. Retrieved from http://www.hhs.gov/ocr/privacy/hipaa/understanding/summary/privacysummary.pdf

U.S. Department of Health and Human Services (HHS). (2007). Basics of risk analysis and risk management. Retrieved from http://www.hhs.gov/ocr/privacy/hipaa/administrative/securityrule/riskassessment.pdf

Wheeler, A. M. N., & Bertram, B. (2012). The counselor and the law: A guide to legal and ethical practice (6th ed.). American Counseling Association: Alexandria, VA.

Yu, E. H. (2013). HIPAA privacy and security: Analysis of recent enforcement actions. Journal of Health Care Compliance, 15(5), 59–61.

 

Tyler Wilkinson, NCC, is an Assistant Professor at Mercer University. Rob Reinhardt, NCC, is in private practice in Fuquay-Varina, NC. Correspondence may be addressed to Tyler Wilkinson, 3001 Mercer University Drive, AACC 475, Atlanta, GA 30341, Wilkinson_rt@mercer.edu.

Book Review—Mental Health Practice in Today’s Schools: Issues and Interventions

Public schools today face an ever-increasing array of issues that impact both the school climate and the overall mental health of students at all levels—elementary, middle and high. In order to identify these issues and provide successful, research-based interventions, Raymond H. Witte and G. Susan Mosley-Howard have brought together practitioners and experts in the field to present a concise yet comprehensive resource to assist both school support professionals and clinical mental health practitioners who work with school-age children. Mental Health Practice in Today’s Schools: Issues and Interventions provides essential guidance in serving the mental health needs of all students.

The first part of the book focuses on core professional topics that help facilitate the role of mental health practitioners in schools’ student support services. Because Response to Intervention has become a focal point for the identification of special-needs populations and of students with chronic behavioral challenges, procedures are presented for screening at-risk students for mental health intervention, as well as for integrating mental health programs within the school community. Authors also discuss how to use counseling microskills more effectively with children of varying developmental levels. In addition, two of the more widely-used and successful theoretical approaches in working with school-age populations, reality therapy and solution-focused brief therapy, are presented by acknowledged experts in the field—Robert Wubbolding and Cynthia Franklin, respectively.

As many educators working in the schools may not be familiar with disorders commonly diagnosed in the school-age population, authors identify these disorders and provide strategies for presenting this information effectively to teachers, administrators and other student support personnel. Likewise, authors offer guidance on legal and ethical considerations when providing mental health services to children and adolescents within the school environment.

Specific issues encountered by educators and mental health professionals working in the schools are addressed in the second part of the book. Bullying is an international phenomenon, and this text provides interventions for assisting both the aggressor and the target of the bullying behavior. School staff members often have a particularly difficult time in developing effective strategies to combat cyberbullying, which is bullying by means of electronic devices and social media. This behavior can cross school boundaries, making it difficult to pursue due to students’ rights to privacy and free speech, and to the extent of the school’s authority to legally intervene. However, bullying can be linked to other issues such as physical or sexual abuse, substance abuse, and suicide, and as such, authors provide suggestions for addressing each of these challenges for school crisis prevention and intervention by mental health professionals working in the schools.

Although some of the information presented by the various authors is more technical in nature, I found this book to be informative, novel in its choice of subjects, and a user-friendly read for practitioners and educators alike. Such topics as student threat assessment and psychopharmacology are necessary but seldom included in mental health practice texts relative to the public schools, making this book a much more comprehensive text for use not only by practitioners but also in the preparation of students in training for the mental health professions. A particular strength of this book is that the authors are drawn from various fields and professional perspectives—psychology, psychiatry, social work, mental health counseling and public education. The text’s only limitation is that I would have liked to see a more prominent emphasis on collaboration with existing student services members, such as school counselors, in support of mental health interventions within the school environment.

Overall, Mental Health Practice in Today’s Schools: Issues and Interventions provides a comprehensive guide to the mental health issues of students in our schools and practical school-wide prevention and intervention strategies to address these challenges. This text will likely serve as an essential resource for mental health practitioners and educators working in the schools for years to come.

Witte, R. H., & Mosley-Howard, G. S. (Eds.). (2015). Mental health practice in today’s schools: Issues and interventions. New York, NY: Springer.

Reviewed by: Michael A. Keim, NCC, Columbus State University, Columbus, GA.

The Professional Counselor

https://tpcjournal.nbcc.org/

Book Review—Love Sense: The Revolutionary New Science of Romantic Relationships

Dr. Sue Johnson, creator of emotionally focused therapy and bestselling author of Hold Me Tight: Seven Conversations for a Lifetime of Love, explores the science of love in her latest book Love Sense: The Revolutionary New Science of Romantic Relationships. In this day and age, we have the knowledge to “split the atom and soar into space,” yet we lack a clear and rigorous understanding of the instinct and connection that drives the human life. Dr. Johnson states that love is “far from being unfathomable;” it is “logical and understandable.” Dr. Johnson wrote Love Sense as a guide for finding the way to more fulfilling, lasting love.

In part one of Love Sense, Dr. Johnson starts with an explanation of the emotional bond of love, covering John Bowlby’s attachment theory. In part two, she describes emotion, the brain and the body, weaving in years of scientific research ranging from Freud to genetic research. She normalizes the common and relatable experiences that are difficult parts of love, claiming, “Love relationships aren’t meant only to be joyrides; they’re also restorative and balancing meeting places where negative emotions are calmed and regulated.” Dr. Johnson covers the neurochemistry of love, including a detailed account of hormones and the brain. The context of the information relates to emotional bonding between parent and infant and between adult lovers.

After describing the science of love, or the physiological reactions, Dr. Johnson describes love in action in part three of Love Sense. She shares how love moves and evolves over time, stating that “relationships are not static, frozen-in-time unions; they are living, breathing organisms.” Dr. Johnson covers how bonds become unraveled and renewed. In part four, Dr. Johnson concludes with two chapters about the application of the new science on attachment and love. Providing a love story example, Dr. Johnson shows how one couple—Andre and Cleo—move from a breakup to bonding. This is a “down-to-earth story of love made possible by the love sense that is now available to us all.”

In addition to factual material, Love Sense includes experiment sections at the end of chapters, which give readers an opportunity to apply the material. Readers can utilize the scientific information presented to gain emotional understanding in the present moment. Counselors can expand their understanding of the driving force in relationships, hopefully improving their clinical effectiveness. Laypersons can read scientific information in a digestible form and apply the new information in their relationships, a task that is made easy through the book’s experiment sections. Whether the reader is a professional or not, Love Sense provides new insight on what is so “vital to our existence”—love.

Johnson, S. (2013). Love sense: The revolutionary new science of romantic relationships. New York, NY: Little, Brown.

Reviewed by: Traci P. Collins, NCC, doctoral student in counselor education at North Carolina State University and Managing Editor of The Professional Counselor.

The Professional Counselor

http://tpcjournal.nbcc.org

Book Review—The Elements of Counseling Children and Adolescents

The Elements of Counseling Children and Adolescents is a brief, yet beneficial, text that offers an introduction to anyone exploring developmentally appropriate strategies for addressing the problems of children and adolescents. As is, the text may be useful for students in all branches of mental health.

The authors begin the book by reviewing the concepts of setting the stage for counseling (Chapter 1), the process of counseling (Chapter 2), and self-awareness and growth (Chapter 3). Though these topics are covered in many introductory counseling books, here the authors focus on what counseling can look like when working with children and adolescents. Likewise, the authors discuss setting the stage, the process of counseling, and self-awareness and growth from a developmental perspective for working with non-adult clients. One might also conceptualize Chapters 2 and 3 as concerning the fundamental skills used in counseling tailored for children and adolescents. Within these chapters, as the authors explore each skill, they provide mini-transcript examples to demonstrate each skill.

In Chapter 4, misconceptions and assumptions are examined. The authors remind readers that children and adolescents are not adults, and that progress and growth may not occur in the same fashion or resemble that of adults. This chapter, as a prelude to Chapter 5, warns of cookie-cutter approaches and emphasizes the importance of the client’s individuality.

Chapter 5 provides a brief description of evidence-based and contemporary practices that are useful when working with non-adult populations. The chapter covers the more conventional modalities (e.g., brief, solution-focused, cognitive behavioral and behavioral) as well as the less conventional (e.g., play therapy and creative techniques). Both individual and systemic counseling models are described. Chapters 6 and 7 end the book’s coverage of topics by discussing crisis intervention, mandated reporting, grief and counselor self-care.

The book is easy to read and the chapters flow in a succinct manner. Its greatest strength is the use of the “elements of” format to highlight specific topics that are important for all to consider, regardless of whether the reader is a novice or educator. In total, 59 elements are described. Also, as previously noted, each chapter includes mini-session transcripts as well as summary and discussion questions. These aspects allow for further discussion within educational settings or reflection by individual readers. Finally, the appendix provides a “how to” section for use in educational settings.

In addition to its strengths, The Elements of Counseling Children and Adolescents also has some limitations. The text is only introductory and does not provide enough depth to be used as the primary text for a class on counseling children and adolescents. At only 126 pages, the book lacks information on the application of evidence-based practices to specific disorders. The authors mention the tenets of each modality as well as some of the disorders that each modality may be used to treat; however, there is no exploration or description of, for example, what “Modality A” looks like when used with “Disorder A.” The text frequently and appropriately describes the importance of individual differences and integrative practice; however, it fails to explore cultural differences within child and adolescent populations.

The best application of the text for counseling professionals would be as a supplemental text in a class on counseling skills and techniques. The average skills class covers the basic counseling microskills from the perspective of working with adults. With this said, this text would make an excellent companion to apply basic skills to working with non-adult populations.

Cook-Cottone, C. P., Kane, L. S., & Anderson, L. M. (2015). The elements of counseling children and adolescents. New York, NY: Springer.

Reviewed by: E. Franc Hudspeth, NCC, Henderson State University, Arkadelphia, AR.

The Professional Counselor

https://tpcjournal.nbcc.org/