(By Judy Beaupre)

Kids will be kids.

We’ve been saying it for years, sometimes as an explanation for actions that defy adult understanding, occasionally to dismiss or downplay the need for personal accountability, and—perhaps way too often—to convince ourselves that the sometimes-alarming behavior we witness in the young people around us is “normal.”

Take bullying. Once seen as a “rite of passage,” bullying was a label for such innocuous behavior as taping a “call me stupid” sign to the new kid’s back, hiding earthworms in a classmate’s lunchbox, or—as depicted repeatedly in the musical comedy series, Glee—tossing a slushie in someone’s face. Messy, uncomfortable, embarrassing—but not all that damaging in the long run. That has changed, or at least our recognition of the sometimes-dire consequences that can accompany bullying has. Today’s version of peer-to-peer torment has captured media attention as a far more disturbing trend—one that transcends hurt feelings and strawberry-stained clothing, instead being blamed for suicides, catastrophic acts of mass revenge, and long-term mental health consequences for victims, perpetrators, witnesses, and family members.

“Between 15 and 30 percent of students in today’s schools are involved with regularity in bullying—and often with negative consequences,” says Dr. Dan Olweus, a professor of psychology at the University of Bergen in Norway, who has devoted more than 40 years to bullying research and is recognized as an international authority on the subject.

Bullying By the Numbers

“Victims suffer from anxiety, depression, poor self-esteem—they view the rejection by their peer group as too hard to handle.” Others put the prevalence of bullying far higher than Olweus’ estimate. Research published in 2009 in the Journal of Adolescent Health reported that, while only 20 percent of students reported involvement in physical bullying—either as a victim or a bully—more than half were involved in social bullying (defined as social exclusion or spreading rumors) and even more—54 percent—were on the giving or receiving end of verbal bullying. The most recent addition to the bully’s arsenal—cyberbullying—is the fastest growing, accounting for an ever-increasing portion of teen harassment cases. This 21st-century twist on the age-old practice of picking on classmates encompasses the rampant use of the Internet, email, and texting to demean or harass others. Cyberbullying is, in some ways, the most dangerous; it extends the bully’s timeframe for making a peer’s life miserable from school hours to 24/7, and vastly expands the reach of ugly rumors, innuendo, and compromising or humiliating photos.

While bullying has been around for decades—if not centuries—social scientists have only recently gathered enough empirical data to draw conclusions about the phenomenon’s long-term psychological effects. According to researchers, students who have been repeatedly intimidated or persecuted are far more likely to be emotionally distressed and twice as likely as their non-involved peers to experience psychosomatic symptoms such as headaches and abdominal pain. Most alarming of all is the connection that has been suggested between bullying and suicidal ideation.

During the past year alone, news media have been peppered with the stories of children and teens who became victims of what is sometimes referred to as bullycide.

In Massachusetts, a 15-year-old high school girl whose family had recently moved to the United States from Ireland was taunted with cultural slurs—and physically harassed as she walked home from school—until she hanged herself in the stairwell of her home. In Minnesota, two eighth-grade girls fulfilled a suicide pact after repeatedly indicating that they were ostracized and bullied by classmates. And in New Jersey, an 18-year-old Rutgers University student jumped to his death from the George Washington Bridge after classmates secretly shot video of him in an intimate encounter with another male student and streamed it online.

While the reasons students are targeted for harassment are many, “being different” leads the list. Few groups are singled out more frequently than students who are—or who are perceived to be—gay. One study produced in 2010 by Iowa State University researchers showed that more than half of lesbian, gay, bisexual and transgender (LGBT) youth had been cyberbullied in the 30 days preceding the survey. For many, this led to depression and—for 26 percent—thoughts of suicide.

“There’s a saying that we’ve now changed to read, ‘Sticks and stones can break my bones, but words can kill,’” Warren Blumenfeld, an assistant professor who co-authored the study, told the ScienceDaily website. “Pre-adolescence through adolescence is a time when peer influences are paramount in a young person’s life. If one is ostracized and attacked, that can have devastating consequences—not only physically, but on their emotional health for the rest of their life.”

Recent research published this year in the Journal of School Health supports Blumenfeld’s contention. According to the study, LGBT young adults who had been victimized during adolescence were more than five times as likely to report having attempted suicide and more than twice as likely to report clinical levels of depression.

“We now have evidence of the lasting personal and social cost of failing to make our schools safe for all students,” said University of Arizona professor Stephen Russell, the study’s lead author. “In our study, we see the effects of school victimization up to a decade later or more.”

Tackling the Problem

Teen angst is nothing new, and has long provided a steady stream of clients for mental health professionals who work with this population—child and adolescent psychologists, clinical counselors, school psychologists, and marital and family therapists.

The growing recognition of bullying’s long-term impact, however, has caused professionals to take a closer look at causes and consequences, and to develop more proactive approaches to curbing the practice’s most egregious forms and teaching victims resilience strategies.

Bystanders and Bullies

Dr. Olweus, the international bullying authority quoted earlier in this story, used his four decades of research to develop the Olweus Bullying Prevention Program, which has been implemented in elementary, middle, and junior high schools across the country and claims to have reduced bullying by up to 70 percent in some schools. Its focus is on improving school climate, training teachers and staff to recognize and deal with bullying incidents, and involving parents in conversations about how best to support their children.

Dr. Dan Koonce, associate professor of school psychology at The Chicago School’s Chicago Campus, is a strong believer in using Positive Behavior Intervention and Supports (PBIS), a systems approach to creating a positive social climate in schools, as a weapon against bullying. Rather than focusing solely on discipline, PBIS incorporates proactive strategies for defining, teaching, and supporting appropriate student behaviors.

It is a two-part approach, he says, involving both a teacher-training component and direct instruction of all students in how to identify bullying and how to respond—as a victim or as a bystander.

“Some teachers are not fully aware of what’s happening—especially when relational aggression is taking place,” Dr. Koonce says. “Texting can be just as dangerous as more outward forms of bullying, and teachers have to know how to identify and address it.”

Unfortunately, addressing the issue on a schoolwide or even communitywide level is often not enough. All 50 states have enacted some form of anti-bullying legislation—many specifically targeting cyberstalking, cyberharassment, and cyberbullying. In March 2011, President and Mrs. Obama hosted a White House Conference on Bullying Prevention, which included leaders from the American Psychological Association, educators, politicians, and mental health professionals.

Participants discussed ways to empower students to come to the aid of classmates who are being victimized, and how to involve family members in teaching their children more respectful ways of interacting with their peers.

Too often, bullying incidents become a matter for the legal system, typically when they lead to violence. Both adults and juveniles have faced charges when their harassment activities resulted in attempted suicide or other injuries, and victims have been known to lash out, taking revenge on those who have tormented them. Sometimes, too, verbal taunting or cyberbullying is just the first step in what eventually becomes more overt acts of violence.

Turning to Violence

In 1999, Eric Harris and Dylan Klebold, who were widely reported to have been bullied in school, went on a shooting rampage at Columbine High School in Littleton, Colo., killing 13 including themselves, and injuring 21 others. Seung-Hui Cho was 23 when he opened fire at Virginia Tech, killing 32 before taking his own life, but authorities said that much of his anger could be traced to his high school days, when fellow students had made fun of his shyness and accent.

The 21st Century Bully: Online, Not In Your Face

Dr. James Shaw, assistant professor of forensic psychology at The Chicago School’s Los Angeles Campus, has spent years studying the causes of teen violence. His book, Jack and Jill and Why They Kill: Saving Our Children, Saving Ourselves, shares the stories of 13 adolescents serving time in state youth prisons for murder. His insights were the subject of a keynote address he gave at the first commemoration of the Columbine tragedy. While the juvenile inmates he interviewed did not necessarily point to bullying as a cause for their rage, all articulated feelings of alienation, isolation, and being unloved and unlovable. They expressed disappointment in a person they trusted and with whom they had a connection.

“There is no uniform behavior or set of symptoms for children who turn to violence, although the news media would like to have everyone fit into a formula,” Dr. Shaw said. “The closest I can come is to say all were unhealthy children psychologically and emotionally, and all felt some level of betrayal.” An important thing to recognize, he emphasized, is that “these are kids, not fully formed, and not completely matured psychologically.” He added that the majority did not understand the gravity of what they had done until their court appearance, when they realized the impact their actions had had on family members and the community.

In an effort to counteract teen violence, Dr. Shaw has founded the B.R.A.V.E. (Be Resilient Avoid Violence Everywhere) program, through which he helps children recognize and resist the pressure to engage in any form of violence or bullying as a means of problem-solving. The project has taken off, gaining recognition throughout the criminal justice system, and has been cited by the Philadelphia Regional Office of the FBI as “an example of best community practices.”

Dr. Shaw contends that while parents have responsibility for bringing up children who can readily distinguish right from wrong, schools need to do a better job of addressing aggressive activities. “We need a violence-prevention curriculum that is taught side by side with social studies and English,” he says. “If we can mandate driver’s education, why can’t we require this too? Social driving—social navigation—is as important as anything else we teach in school.”

It’s real-world learning at its best: a two-credit class called Hostage Negotiations, offered as a capstone to students in The Chicago School’s Forensic Psychology program. The course teaches skills and communication techniques needed to de-escalate critical situations, as well as an understanding perpetrators’ psychological profiles and the ability to manage stress. Dr. Nancy Zarse (Psy.D. ’89), associate professor, developed the program based on training she received through the Bureau of Prisons. It is the only known program of its kind offered by an educational institution.

Explore the different stages of hostage negotiations by clicking the image below and selecting “Next” to scroll through the entire gallery.

Student Martinette Zeeman negotiates with the hostage taker. Her goals are to use active listening skills to calm the perpetrator, while also gathering information and assessing his psychological state. What she learns will determine the team’s approach.

Lisa Britton, Travis Ickes, and Nydia Gonzalez work as a team to organize information they have gathered and develop strategies for negotiating the safe release of the hostages.

Kristin Collins fills the role as primary negotiator while Roman Grubbs coaches her. The use of a “throw phone” (thrown in to the hostage taker as a means of communication) allows the coach to hear the conversation and make suggestions to facilitate the negotiations.

The tactical team leader, an FBI agent on the SWAT team, reviews the intelligence gathered to date, and seeks additional information necessary to form command decisions. The involvement of law enforcement professionals adds a realistic flavor to the role play.

Students successfully negotiate the surrender of the hostage taker, who is arrested upon release. Andrew Austin (M.A. ‘10), in handcuffs, is a graduate of the hostage negotiation course and the Forensic Psychology master’s program. Currently in the U.S. Army’s Officer Candidate School, Andrew returned as a volunteer for the role play.

The debriefing session and afteraction review is a critical component in the day’s role play. What went right? What went wrong? Now in its fifth year, the training model has evolved over the years. “I learned after one of these role plays that students needed to talk about what they were feeling,” Dr. Zarse says. “I have now incorporated a longer after-action session that allows time for that.”

{By Lindsay Beller}

An elderly hospice patient was so close to death that her team of health care providers, on hand to address all needs related to her mind, body, and spirit, could not understand why she was still alive. From a biological standpoint death should have come, but in what seemed like defiance of her physical condition, she held on tight to life.

When Dr. Todd DuBose stepped in her room, he found her awake and riddled with anxiety. During their conversation, the woman tearfully revealed that she was afraid to die because of a deep-seated fear that her mother—with whom she had a falling out with decades earlier—would meet her at the gates of heaven and keep her out. Her talk with Dr. DuBose likely brought her the measure of peace she needed to let go because later that afternoon, the woman passed away.

By his own account, Dr. DuBose has had thousands of similar conversations, underscoring how common it is for terminally ill patients to experience mental anguish when they know the end is near. “There are often issues related to guilt, regret, resentment, feeling a lack of worth or mattering of one’s life, worrying about those left behind. I’ve seen people hang on because they are concerned about the well-being of those who survive them,” he said. “Psychologists could move into those spaces.”

They could, but for the most part, they have not. Dr. DuBose, an associate professor of clinical psychology at The Chicago School who focuses on sudden and traumatic loss, and previously worked with AIDS patients as a hospital chaplain, is more the exception than the rule. In the four decades since noted psychiatrist Elizabeth Kübler-Ross’ seminal book On Death and Dying brought the taboo subject of death into the open and legitimized the emotional issues that terminally ill patients experience through the five stages of grief, psychology has not had a clearly defined role in end-of-life care.

But current trends suggest a growing awareness that mental health providers in this area are needed. In the U.S. nearly 50 million more people will join the 65-and-over crowd by 2050, while an increasing body of research finds patients want to have a “good death,” but instead die in pain, in psychological distress, and with family members or caregivers who may not have fully understood the prognosis and expected to have more time with their loved one.

5 Stages of Grief

Stemming from this is more widespread integration of palliative care units in hospitals, where an interdisciplinary team of health care providers, including a mental health specialist, focus on quality-of-life improvements over curative treatment for sick patients, regardless of their life expectancy. Under the umbrella of palliative care is hospice, which offers a similarly holistic approach to terminally ill patients, typically in a home or longterm care setting. From 2000 to 2008, the number of palliative care programs in hospitals increased by almost 126 percent, while last year, nearly 42 percent of all deaths in the United States occurred in the approximately 5,000 hospices in the country. Despite increasing integration of such programs in recent years, they still lag far behind what is needed.

The expertise that psychologists have in assessment, research, evaluation, and counseling; their considerable involvement with chronically ill patients; and a general acceptance of the holistic and integrated health care philosophy suggest that they could bring useful skills to the end-of-life arena. But a lack of educational opportunities, few financial incentives, a complex health care system, and, for some, a general discomfort with death and treating patients at the end of their lives have all explain why psychologists rarely occupy this niche. “It’s almost as if when you’re ready to die, people feel the work of the psychologist is over when in fact it’s just the beginning,” Dr. DuBose said.

Outside the System
One could argue that historically, psychologists have demonstrated little interest in working in end-of-life care. The field was just beginning to advocate for more training in clinical settings after the endorsement of the Vail Practitioner Scholar model when the first hospice opened in 1974 in Connecticut, introducing a more holistic approach to treating terminally ill patients. “Historically speaking, that’s not where psychologists were,” said Dr. James L. Werth Jr., professor of psychology at Radford University. “They were in group or private practice in the early years.”

Meanwhile medical advancements had begun to extend life, and the notion of caring for the whole person, that is, the physical, emotional, social, and spiritual needs of the patient, was catching on. In 1983, Congress created the Medicare benefit for hospice care, which established several guidelines that needed to be met in order to cover the cost, including the requirement that every patient have a health care team that consisted of doctors, nurses, counselors, a social worker, speech-language pathologists, hospice aides, homemakers, and volunteers. The counselor was often a member of the clergy, and the social worker provided psychological support for patients and their families. “There’s a difference in opinion in how interested psychologists were in being a part of government programs,” Werth said. “Social workers were more a part of the system. By not advocating for ourselves, we therefore got written out.”

Social workers, on the other hand, received training in such areas as case management and discharge planning that served them well in this role. “It’s a natural fit for them to be included in these teams in hospitals and hospices,” Werth said. “They have courses on hospice and health care built in whereas it’s an elective to take these in any health psychology programs. Psychologists are playing catch up.”

Although the field of psychology has since expanded into different settings and embraces a more integrated approach to health care (see cover story), the hospice benefit has not changed since its inception nearly 30 years ago. The team is defined in the same way, and the small per diem— which remains the same regardless of where the patient is in his or her illness—only covers services provided by the team. Additional costs incurred by a psychologist that are related to the patient’s illness would need to be covered by the hospice or the patient (psychologists can be reimbursed for providing services for concerns not directly related to terminal illness, although there is a common misconception that they cannot). While psychologists are occasionally brought in to consult, the perceived lack of reimbursement is a key reason why psychologists do not often provide services in these settings.

Tips: Working with a Dying Patient

But a push toward more integrated care could bring more psychologists into the fold. In recent years the field has begun to champion the idea that a more collaborative and streamlined approach toward treating patients could reduce medical costs and improve care, and research has supported this belief.

One of three goals in the American Psychological Association’s new strategic plan is to expand psychology’s role in advancing health. “The big piece is integrated care.” said Werth, who chairs of the APA Committee on Rural Health. “The organization realizes that we need to move in this direction to stay viable in the field.” Some psychologists who work with terminally ill patients have faced challenges in trying to accomplish this.

Dr. Merla Arnold, a registered nurse and geropsychologist who works in long-term care settings with aging adults, receives little response when she reaches out to her patients’ physicians to discuss the impact of medications on their mental health. “The nature of our health care system as a whole is hierarchical,” she said. “The physicians are at the top, and everyone else is under them. That has to collapse for a truly integrated approach. It has to be less hierarchical and more cyclical.”

Doctors may also have a different mindset in treating the terminally ill, said Marsha Nelson, vice president of American Hospice Foundation. “This can be an uncomfortable topic for physicians. They’ve been trained to save people, and death may be perceived as a failure.”

Psychologists are not immune to this thinking either, said Dr. DuBose. “I think we (psychologists) are still impacted by medical modeling that sees the job to be fixing, curing, making better. If you have that operating, it’s hard not to understand death as a threat,” he said.

A Greater Role
There are signs that the field not only wants to define a greater role for psychologists in end-of-life care, but has made inroads too. The American Psychological Association has initiated various efforts in the past decade. In 2000, a report from the APA Working Group on Assisted Suicide and End-of-Life Decisions found evidence that neither the discipline of psychology nor other professions that care for terminally ill patients saw end-of-life care as an important area for psychologists.

A year later, the APA convened an Ad Hoc Committee on End-of-Life Issues and identified four areas in which psychologists could be useful: before illness occurs, after the diagnosis and treatment begins, during the advanced  stages of the illness, and after the death of the patient during the grieving process.

Psychologists could have numerous roles, reported a 2003 article published by committee members in Professional Psychology: Research and Practice: helping patients make decisions about end-of-life care, developing community education programs, counseling patients who experience depression or anxiety, supporting caregivers, and providing bereavement counseling for survivors, to name a few.

The article also cited the growing field of geropsychology—which addresses the needs of the aging—as well-positioned to provide mental health services and manage symptoms of older adults in nursing homes. This summer after more than 20 years of efforts to bring the field to the forefront, APA formally recognized geropsychology as a specialty of
psychology, a move that brings more credibility to the field and paves the way for more educational opportunities. The APA also listed geropsychology as one of the top 10 growth areas for psychologists in its magazine, The Monitor.

In Europe, the newly formed European Association for Palliative Care’s Task Force on Education for Psychologists in Palliative Care is seeking to define a role for psychologists in these settings and establish specialty postdoctoral curricula. Psychologists have also led research efforts in the growing interdisciplinary field of thanatology, which is the study of dying and death.

But ultimately there is a need for psychologists to want to be more involved in end-of-life care. Dr. Arthur Kovacs, a psychologist who works with older adults and occasionally treats clients who become terminally ill, was frank in explaining his reservations in working patients at the end of their lives. “We find it upsetting and we avoid it,” he said. “We don’t get much training. Some of my colleagues make a living of rising nobly to the challenge. I don’t know how they do it. It’s terribly lacerating. It’s demanding. It’s terrifying.”

A cultural shift is necessary for this to change, said Dr. DuBose. “We have to shift our thinking away from the avoidance of death,” he said. “We have to embrace death and think about it as a part of life.”

Despite working in a city with a large Latino population, Carrillo knew few other mental health providers who spoke Spanish and understood the culture, which compromised his ability to connect clients with other services available in the community.

When Carrillo joined the Latina/o Mental Health Providers Network (LMHPN)—an initiative started by The Chicago School’s Center for Latino Mental Health (CLMH) to train more mental health professionals to serve the growing Latino community—he met Carlos Lopez, who runs domestic violence groups for couples less than two miles away. “We’ve been able to talk about the services we provide,” Carrillo said. “I feel more comfortable referring clients to the program because I know him personally.”

This type of connection exemplifies what Dr. Hector Torres, assistant professor of clinical counseling and CLMH coordinator, had in mind when the network launched in 2009 with a $130,000 grant from the Chicago Community Trust. In September, the Trust renewed the grant with an additional $140,000 following a successful first year, in which the network recruited 75 members—more than twice as many as projected. “We connect with the community through the network,” Dr. Torres said. “We have two goals: to allow current providers to know and refer each other; and to increase the number of providers who are culturally competent.”

The network has worked to achieve this in a variety of ways, particularly as a poor economic climate has led to statewide cuts in mental health services and added urgency to connecting agencies and practitioners with each other. Bimonthly meetings allow members to network and take continuing education workshops designed to increase understanding of Latino culture and knowledge of effective mental health interventions, new research, and other relevant topics. After the network launched last year, staff made nearly 40 site visits at community-based agencies to assess needs for providers and services and launched a website (lmhpn.tcscenters.org) that enables members to interact with each other and share resources.

The LMHPN has also given students like Ana Sierra the opportunity to participate. During an internship at The Counseling Center of Lakeview, where Sierra counseled victims of domestic violence, she held a workshop for mental health providers on Latin American gender roles. When she realized the group knew more about male (machismo) than female (marianismo) gender roles, she conducted an exercise that put the practitioners in the shoes of a Latina woman. “We need to know what these terms mean to work successfully with Latinos in therapy,” she said.

Latino Mental Health Facts

In all, 10 Chicago School students who are earning master’s in clinical counseling degrees with a concentration in Latino mental health developed a project for the network, including taking additional case loads, conducting outreach, and running culturally focused workshops on topics like positive parenting, suicide awareness, and supporting Latino adolescents. The Chicago School’s Department of Community Partnerships also placed 56 students in member agencies, providing nearly 7,000 hours of service.

With the grant renewal, LMHPN activities are already well underway. In October the network sponsored the 2010 Latino/a Behavioral Health Conference along with the Illinois Department of Human Services and The Chicago School of Professional Psychology and brought more than 200 behavioral health professionals together to address how to improve mental health services for the Latino community.

The network also plans to expand focus on advocacy, professional development, and promotion of mental health careers for Latino students, and launch a local media campaign to raise awareness about Latino mental health issues. Ultimately the network fosters a deeper commitment to address the long underserved mental health needs of the Latino/a community. “Bringing people together who have the same interest in working with the Latino community creates an energy to better provide and advocate for the need for services,” Carrillo says.

A participant in The Chicago School’s creative arts therapy sessions for children of Illinois National Guard personnel, Micah had been told he could make anything he wanted out of the discarded materials available. His creation—held together by hot glue and masking tape—offered a revealing glimpse into the thoughts that preoccupied him. His dad, who had been deployed to Afghanistan, was home now. But somehow the anxieties that had defined his world for the past year didn’t go away so easily.

Deployment Stages and Children's Responses

“The kids we see are at all different stages of willingness to talk,” says Drew Gleitzmann, a first-year Clinical Psy.D. student who worked with Micah on his project. “Some won’t admit to their fears, while I’ve had 6-year-olds say ‘I’m afraid Daddy will die’.” The experience of working with these children is a powerful one that keeps bringing him back, Drew says. Before coming to this session in Joliet, he had been to at least eight similar sessions that The Chicago School offers—in partnership with the Michael Reese Health Trust—in towns throughout Illinois.

Part of the Guard’s Family Reintegration Program, the initiative—which The Chicago School has recently named the Home Again project—uses music, drama, and art to help children begin the process of acknowledging and addressing their anxieties. Psychology graduate students attend the Saturday morning activities, working as volunteers with participants and assisting therapists from the Institute for Therapy through the Arts (ITA ).

Under the direction of Clinical Psychology Assistant Professor Ted Rubenstein, who designed the project, they lead children ranging in age from 3 to 15 through activities using songs, musical instruments, painting, and performing as outlets for unvoiced feelings.

“We integrate the activities so that one builds on another, giving kids more opportunity to deal with what’s really on their mind,” says Katherine Dillingham, an ITA drama therapist who coordinates many of the sessions. Micah illustrated her point by using his tank in an impromptu play that featured an imaginary “Colonel Bob” who carried wounded survivors to safety and looked in vain for a way back to base. When Micah was asked if his dad drove a tank in Afghanistan, though, he just shrugged.

“Our purpose is not to provide intensive therapy at these sessions,” Dillingham says. “We’re not set up for that. We just want to give them permission to start a conversation at home.” Children leave the session with a workbook of activities they can do alone and with their family, and with a list of referral sources for families who want to pursue follow-up services.

Micah is among the 700,000 U.S. children who had at least one parent stationed overseas for military duty last year. An APA Task Force on Military Deployment Services, published in 2007, identified the “unique constellation of stressors” on these children and summarized their responses to deployment, which varied by age, development stage, and family resilience factors. While preschoolers are likely to react with tantrums and separation anxiety, the report said, school-age children may experience mood shifts and declines in school performance. But deployment was found to have particularly detrimental effects on adolescents’ lives, often overtaxing their limited coping resources. See chart.

Tips for Professionals Dealing with Military Families

Although families look forward to their soldier’s homecoming—often with unrealistic expectations of picking up where they left off—such reunions usually come with their own set of stressors.

“Combat deployment can produce enormous ambiguity and chronic anxiety, but families tend to experience even greater levels of ambiguity when the soldier returns,” says Dr. Shelley MacDermid Wadsworth, director of the Military Family Research Institute at Purdue University. “The place that each person has in the family has to be renegotiated and it’s not always easy. A child might have reached puberty and have totally different expectations of the parent, and the spouse might have learned to make all the decisions and not be eager to give up this new level of autonomy.”
Good communication skills play a critical role in post-deployment family life, but it can be difficult to know what the boundaries are, Dr. Wadsworth says.

“Family members may say they want to hear about the soldier’s experiences, but the soldier can be dubious, not knowing whether they are really ready to hear what he has to confide. It can cause a lot of anxiety—not knowing whether others will really understand.”

The APA Task Force reported that families of National Guard and Reserve personnel face even greater challenges during and after deployment than active duty families do. Both soldiers and family members are likely to experience higher stress because they are less prepared for the realities of combat and family separation. They often feel isolated in what they are going through because they are not surrounded by other families in the same situation.

Children can have a particularly hard time in a non-military environment if they’re the only one with a parent in harm’s way, Dr. Wadsworth says, adding that they can be very sensitive to a teacher or classmate who expresses anti-war views.

“They don’t want to be outed. Young children, particularly, are not yet ready to appreciate the political complexity of such viewpoints and they see the comments as criticism of their parent.”

Although the Home Again program has only been implemented in Illinois so far, The Chicago School is seeking funding to expand it geographically. Plans are also underway to develop modules of the project that specifically target preschoolers and teens, and that are adapted for families of fallen soldiers, families during deployment, and long-term follow up for families currently being served.

For those who get the news, it’s a moment of profound tragedy, one that will change their lives forever. And for those charged with delivering the message, it is usually “the worst duty they have ever been assigned.”

Notifying the next of kin of a military death.

By Pam DeFiglio

It’s the reason that armed services families panic the moment they see military officers coming up the walkway to their home. But those moments—which have been delivered in one form or another as long as men and women have marched off to war—have prompted all service branches to begin looking to psychology as a means of helping all participants involved: the survivors, the officers who make the notification, and the casualty assistance officers, who spend months—even years—providing assistance and emotional support to the family.

Psychology factors into the military’s decision to make notifications via a personal visit, and it influences the way military personnel interact with the survivors. During World War II, much-dreaded telegrams were used to announce deaths, but that was seen as cold and detached, said Army Col. Paul Bartone (Ret.), a research psychologist. The various branches of the military experimented with making the process more personal in the years since. Since at least the 1980s, military policy requires that an officer, accompanied by a chaplain if possible, make the notification. They put great emphasis on reaching survivors quickly, before the family can hear the news from someone else or see it on television.

“The personal face-to-face notification of a death is more respectful, and it conveys a higher level of respect and concern for the family,” said Bartone, is a senior research fellow at National Defense University in Washington, D.C. “From a psychology vantage point, the personal visit helps families cope with the devastating experience.”

Originally, the military sent one person to both deliver the news and then support the family and assist them with funeral arrangements, death benefits, and other matters.

“But for many people, there’s a negative association with the face of the person who brings that bad news,” said Bartone. “They’re having an acute stress reaction. They’re having all the nervous system arousal. There may be an actual imprinting process that occurs of the various images immediately surrounding that time frame—predominantly the face and image of the person bearing the bad news.”

War Casualties

Knowing this, the Army now uses a team of officers to make death notifications, employing a “bad cop-good cop” process designed to make it easier on family members who receive the news. The casualty notification officer, who is required to be of equal or higher rank than the deceased, plays “bad cop,” delivering the horrible news. Then he leaves and the casualty assistance officer steps in as “good cop” to comfort the family and gently hold their hands through the process of funeral arrangements, delivering personal belongings, completing paperwork, and applying for benefits.

The 2009 movie The Messenger shows actor Woody Harrelson’s character training actor Ben Foster’s character for the notification role in the Army. They deliver their devastating message respectfully, state the few details of the death that are known, offer condolences, say that a casualty assistance officer will be in touch soon, and depart. The casualty assistance officer usually makes contact within hours.

The personal face-to-face notification of a death is more respectful, and it conveys a higher level of respect and concern for the family.

The Marines bring the two roles closer together. Gunnery Sgt. Shawn Doty of the 2nd Battalion, 24th Marines serves as a casualty assistance call officer in the Chicago area, and goes to the survivors’ home as part of a four-person detail. The commanding officer makes the notification, then literally steps back and introduces the chaplain and casualty assistance officer.

“Then it’s our turn,” said Doty, who related that families have told him they can’t bear to see the casualty notification officer for some time afterward. And, since Doty is the one who will be supporting them for several months, he doesn’t want them to see his face during the notification.

“Sometimes you’re just standing there in silence—everyone’s in shock,” said Doty, who has been performing this duty for four years and has had to deflect threats from an angry father and sit for hours with a distraught mother because she had no one else. “We get all kinds of reactions—anger, total disbelief, yelling—things like, ‘it’s the Marine Corps’ fault, ‘What did you to my baby?’ Mothers always seem to know when something is wrong. They tell us afterward that they had an intuition, and when they see us, it just confirms it.” he said.

For the next of kin, the experience of hearing a loved one has died lies completely outside their frame of reference, says Dr. Todd DuBose, assistant professor in The Chicago School’s Clinical Psy.D. program. “Not only is it horrifying, the finality and irreversibility of this event has no prior framework with which to make sense of it. And making sense is our way of clawing at the walls as we fall into what feels like oblivion,” he said.

Although neither the notification officer nor the casualty assistance officer receives training or psychological preparation for the job—other than a military handbook that outlines the basic duty they must perform—messengers may request counseling after the fact. Doty speculates, however, that there isn’t really away to truly prepare for such difficult duty.

“You’re going to tell them the worst news of their life. Parents should never have to bury their children,” he says.

It’s sometimes easier for people with faith to cope with the news, he said. The military provides grief counseling to the surviving family members as part of the overall benefits package for survivors.

Eventually, Doty said, many parents find some comfort by joining the Gold Star Mothers association, because only those other parents know what it really feels like to lose a child.

Delivering the tragic news also takes a toll on notification officers.

“Death telling is very taxing on the messenger,” said DuBose. “The messenger embodies the abstraction-turned-reality, the un-thought horror … which becomes upon delivery the sinister visitation of …what is often experienced as personalized evil.”

With this heavy load upon them, notifiers benefit from support.

“I’ve had chaplains tell me one of their main roles is to provide support, and spiritual support, to the notifiers. Once the notification is complete and they’re back in the car, the chaplain shifts his attention to the notifier. That can lead to an ongoing relationship or a referral for counseling,” said Bartone.

Notifiers often feel a sense of guilt, and this can be intensified if the family members target them in angry or accusatory reactions, he said, adding that psychological support can help them understand they’re not responsible and they didn’t cause the intense pain.

“Many notifiers say it’s the worst duty they’ve ever had to do in their life,” said Doty, “but when they look back later, they say it’s the most honorable duty they’ve ever had to do.”

Casualty assistance officers deal with a different set of stressors as they help the survivors with the process of planning the funeral and applying for benefits as well as providing ongoing moral support. Family dynamics can change the nature of the services needed; some families have rifts between divorced parents, or between siblings. Sometimes the death provokes a disagreement between the deceased’s spouse and his parents. Trying to minister to all parties leaves the casualty assistance officer feeling torn and guilty about being powerless to help, Bartone said.

Doty said that in four years of casualty assistance duty, he has learned to compartmentalize the intense emotions. After he leaves a notification or an emotional encounter with a survivor, he’s able to switch off the feelings and go back to his day.

“At first it gets to you, and then you get numb to it. I guess you have to—how do funeral directors do it?” he asked. “I do feel for the family, and I feel bad about this, but I’ve learned to shut it off.”

Dr. Debra Warner, lead forensics faculty at The Chicago School’s Los Angeles Campus points out that while compartmentalization may work for some, everybody handles this kind of stress differently.

People charged with doing this type of emotionally taxing work have to find a way to turn it off, she says, or they would become so drained that they would become ineffective at their jobs. The tragic would become routine to them and they would become callous and lose their humanistic quality.
“You have to be able to leave it at work, or you won’t be able to have a full life,” she says.

In addition to techniques like compartmentalizing, both casualty assistance officers and notifiers can benefit from social support, which Bartone said has been shown to be a potent resource.

One surprising finding from Bartone’s research showed that notifiers who attended the funerals of the deceased showed fewer negative after-effects in terms of depression and anxiety symptoms.

“My interpretation was that those who attended the funerals had a psychological advantage of closure,” he said. “They were able to see the family members after the initial shock, and that facilitated a healthy processing for the notifiers.”

As for casualty assistance officers like Doty, Bartone found that they and the survivors often ended up supporting each other.

“The survivors showed gratitude back to the casualty assistance officer, so in many cases it was maybe not a growth experience, but in many cases it’s very positive. Sometimes they remain lifelong friends,” he said.

That has happened for Doty. He has a crystal-clear recollection of a February 2006 notification visit that was particularly emotional for him; after the notifier gave his report, Doty broke down when speaking to the Gilbert family of Downers Grove, Ill.

“There was just something about that one,” he said.

Since that time, he has become very close friends with the family, particularly the fallen Marine’s father. They recently traveled together to a wedding of one of the deceased’s buddies. Doty said many survivor families keep in touch with the Marines by coming to memorial ceremonies that occur from time to time, and that deceased Marine’s buddies call and e-mail families for years.

“A lot of families don’t want to let go of the Marine Corps. We’re a pretty tight band of brothers. So we keep in touch,” he said. “We’re there for each other.”

Depending on your frame of reference, it has been a seismic shift that has turned communication, socialization, and family life upside down. Or it has been progress at its best, the least to be expected from a new millennium.

Technology. It has redefined the way we learn, the way we think, and the way we live. And it has changed us—for the worse or for the better. Or both.

Dr. Larry Rosen, a psychologist at California State University- Dominguez Hills, sees both sides of the coin. He will play devil’s advocate when others claim that a generation immersed in an unceasing barrage of text messages, Facebook status updates, and tweets have become antisocial beings with serious interpersonal deficits. But he also points to research that links media consumption to physical and psychological health problems.

“We know that this generation sleeps less than any generation before, and we also know that media use leads to unhealthy eating, which leads to all forms of ill-being—including psychological problems, behavioral problems, attention difficulties, and physical symptomology,” Dr. Rosen says. Citing his own research studies, he specifically addresses the issue of multi-tasking—using or viewing several media simultaneously—and its impact on the Millennial Generation, or “the Net Generation,” as he calls it.

“It’s an issue that transcends junk food and lack of sleep,” he says. “In the simplest terms, we could say that when multi-tasking is taking place, more neurons are firing, taking oxygen away from the brain, which results in a negative impact on health in general.”

Digital multitasking has been widely associated with today’s youth and college students, and has produced a deluge of research on the implications and consequences. A 2006 study by the Kaiser Family Foundation showed that the average 8-to-18-year-old spends more than eight hours a day using digital media. Dr. Rosen found that when multitasking is taken into consideration and time spent using each distinct medium is collectively tallied—even though many took place concurrently—Millennials log more than 20 digital hours a day, almost triple the time spent by Baby Boomers. True, that may include passive activities such as listening to music and watching television, but it also represents hefty doses of interactive communication— texting, IM chatting, emailing, and social networking. Add to that the occasional (or not so occasional) video game or charting a virtual path through the glut of information available on the Internet. Dr. Rosen found that Baby Boomers, by contrast, put in only seven collective digital hours a day, with television and music accounting for half of that.

One concern that has surfaced is the effect that heavy technology use has on the still-developing brain. In his book, iBrain: Surviving the Technological Alteration of the Modern Mind, Dr. Gary Small, a University of California-Los Angeles neuroscientist claims that the neurological pathways used in face-to-face communication are not developing in today’s young people the way they developed in previous generations.

Without eye contact, you can miss so many of the subtleties that are a part of interpersonal communication.

“The empathic skills that come from receiving an affirmative nod or an encouraging smile are just not being formed,” he says. “Without eye contact, you can miss so many of the subtleties that are part of interpersonal communication. We can only speculate what this might mean 10 and 20 years down the road. Will digital natives— young people who only know Facebook-to-Facebook communication rather than face-to-face communication—lack the social skills they need?”

Dr. Lukasz Konopka, a Chicago School neuropsychologist, agrees that technology overuse is likely to impact brain development.

“People who use technology as a primary source of communication have very different expectations for their social relationships,” he says. “If they don’t learn to read facial cues, that can translate into poor relationships and make it harder to develop dependency and trust. We have yet to discover what the longterm consequences will be.”

The link between the increasing use of online communication and its psychological ramifications has been the subject of exploration for several years now. In a 2005 survey completed by more than 1,000 mental health professionals and reported in the Monitor on Psychology, isolative-avoidant use of the Internet was identified as a diagnosis in 15 percent of youth clients. Psychologists echoed concerns expressed by Dr. Small and Dr. Konopka, citing an inability by Millennials to read body language and facial cues.

Some researchers also attribute a recent rise in diagnoses of Attention Deficit Hyperactivity Disorder—a 3 percent annual jump between 1997 and 2006, according to the Centers for Disease Control and Prevention (CDC)—to increased media exposure by children whose brains are not yet capable of processing a lightening-fast parade of visual images. The experience, they say, may train young brains to become dependent on excessive stimulation, to become bored with the pace of real life, and to rapidly shift from one stimulus to another. This could explain the propensity of Millennials—who often grew up in front of Sesame Street and animated television programming— to multitask. With an explanation about the plasticity of children’s brains, the American Academy of Pediatrics has recommended not exposing babies under 2 to television.

Although Dr. Rosen refers frequently to the “techno-cocoons” that he says shroud heavy media consumers—particularly this generation— he also disputes the ill effects of too much online communication.

“I would argue that this generation is connecting more and not less, although they may be connecting in a way that Baby Boomers like me don’t think is communication,” he says. “They have an incredible opportunity behind the safety of a computer screen, and are able to say things that they are not sure will be accepted.” He adds that technologies such as ichats and cell phone cameras also mitigate the effect of cyber-communication, actually offering users a chance to view others’ reactions.

Dr. Dave Verhaagen, a North Carolina psychologist who wrote Parenting the Millennial Generation, agrees.

“Technology is part of their DNA—they use it to facilitate relationships,” he says. “When you look at the big picture, you see that they’re pretty relationally skilled. We have to get past the speculation that their use of technology is hurtful to their ability to have relationships.”

Technology is part of [Millennials’] DNA—they use it to faciltate relationships. When you look at the big picture, you see that they’re pretty relationally skilled.

At the other end of the digital comfort spectrum is technophobia, most often associated with the older generations—Traditionalists and Baby Boomers. A decade ago, Dr. Rosen wrote TechnoStress, a book that addresses the overwhelmed feeling that users—especially technology newcomers—get when dealing with the digital overload that was nonexistent a few years ago. Many experts call for strategies to bridge the brain gap that emerges between the older and younger generations. Dr. Small provides a technology toolkit that can bring Traditionalists and Boomers up to speed with their children’s generations, and also puts his UCLA students through a series of empathic listening exercises to help them rebuild the face-to-face skills that have fallen between the cracks of their smartphone key boards.

Consequences of excessive media exposure do not appear to be confined to Millennials. The excessive use of video games—frequently fingered as the culprit in diagnoses that range from ADHD to aggressive behavior—affects a broad age span. While under-30s have distinguished themselves as the masters of multitasking, their use of video games can be matched by Generation X. A new study from the CDC has placed the average age of the adult video gamer at 35, higher than previously believed. But the emerging classification of Internet addiction can also be found among Baby Boom shoppers who frequent E-bay and Traditionalists who take their poker games online.

Although not yet recognized as an official diagnosis, this new form of addiction is receiving attention around the world and especially in Asia, where Internet rehabilitation centers have begun to spring up. Here in the United Stated, the first such facility opened in July in Fall City, Wash., and the diagnosis is being considered for inclusion in the 2012 edition of the Diagnostic and Statistical Manual of Mental Disorders, published by the American Psychiatric Association.

“Everything that is human can be acted out using technology,” Dr. Small says. “Whether it’s shopping or gambling or social networking, technology is just another pathway to addiction.”

Her therapist, Dr. Eric Green, listens intently and then suggests that the fantasy be recreated with different sets of circumstances: what if the king is already free and able to save the princess? And then, what if it’s up to her to save herself?

Dr. Green’s client, 9-year-old Lindsey, is coping with the metaphorical dragon that has been breathing fire into thousands of young lives of late; as the economy has deteriorated and more parents face unemployment, loss of health insurance, and foreclosure, children are sharing in the consequences.

“When caretakers are in economic distress, the cascade of experiential anxiety eventually reaches the kids—kids who are often too young to comprehend the scope of what’s happening,” Dr. Green, associate professor and associate chair of The Chicago School’s Counseling Department, says. “Because they may not have a full understanding of what’s happening, they don’t know how to verbalize their fears and their feelings.”

Lindsey’s case is all too typical, he says. Her mother has lost her job, money is tight, and stress is playing havoc in their household. Through play therapy, Lindsey can create a world that is less threatening, a world in which she can attribute her anxieties to storybook characters rather than claiming them as her own.

“We stay with the metaphor they create,” says Dr. Green, who recently came to The Chicago School from Johns Hopkins University, where he developed a program in play therapy. “It allows children to see the world as safe, stable, and secure.”

Creating fantasies isn’t the answer for all children, though, especially those who have reached adolescence. Teens handle anxiety very differently, says Dr. Breeda McGrath, associate professor of school psychology at The Chicago School. They also understand the implications of financial loss in ways that smaller children cannot.

“For them, it’s often about the college fund. Their initial reaction might be frustration, then loss of self esteem, and then they need to find someone to blame, asking the parent who lost his job why he didn’t choose a different career.” The dangers for adolescents are greater too, Dr. McGrath adds.

“Once a kid is vulnerable, the options for anyone interested in making his life more difficult are broader. He might be more open to experimenting with drugs, for example.”

Play therapy is important in helping young children express their feelings.

In her role as a school psychologist at Glenview School District 34, Dr. Melissa Brown sees the stress many parents experience when confronted with decisions about additional services recommended for their children with special needs.

“It’s no longer an environment where parents say “we’ll just let the insurance pay for it’,” she says. “They really want to do right by their kids, but they’re worried about the co-pays.”

Long-term Consequences

While therapists, educators, and parents share a concern for what has been called the trickle-down effect that the recession is having on children, a longer-term worry hovers in the background: How will today’s crisis affect these same children as they grow up?

Psychologists Rand Conger and Glen Elder, who have spent decades tracking the long-term impact that the 1980s Iowa farm crisis had on the lives of children whose families were impacted, believes that the way parents handle economic crises is the single most critical determinant of how the children fare.

The difficulties that families experienced—which often included a drastic loss of income and forced relocation, often to the homes of relatives—left psychological scars that were apparent for years. Not surprisingly, children from the hardest-hit families tended to suffer academically, socially, and emotionally through adolescence and early adulthood. In turn, poor academic performance resulted in less rewarding and lower-paying jobs.

In follow-up studies of these families and others who have survived economic hardship, Dr. Conger—a distinguished professor of human development at the University of California-Davis—has found that the children who most successfully survived adversity were those with involved and caring parents.

A parent who is dealing with job loss may be using all of his cognitive resources just to cope, and has very little left over for the kids…And while kids don’t understand all of it, they know something is missing, they feel a sense of loss.

“The emotional stress that parents experienced took on many different forms, including depression, heightened anxiety, irritability, anger, and alienation,” Dr. Conger writes. “When that happens, it creates real havoc in family relationships.” He adds that parents who put family first and continued to communicate despite the hardship were able to relieve some of the long-term effects on their children.

“Children weren’t terribly bothered by not having a lot of stuff,” Conger says. “What bothered them was when their parents became angry and irritable and withdrawn.”

Dr. McGrath agrees that a parent’s frame of mind can be crucial in determining how children react.

“A parent who is dealing with job loss may be using all of his cognitive resources just to cope, and has very little left over for the kids,” she says. “And while kids don’t understand all of it, they know something is missing, they feel a sense of loss. Often they interpret it wrong, and think they’re at fault for what has happened with their family.”

School Responses

The National Association of School Psychologists (NASP) acknowledges that parental resilience is a critical factor in a child’s ability to cope, and has developed a series of resources for parents, which are posted on its website. Tips listed in a document, “Helping Children Cope in Unsettling Times: The Economic Crisis,” could have been written by Dr. Conger. They include suggestions such as acknowledging and normalizing children’s feelings, maintaining a normal routine, spending family time, and being optimistic.

Because schools frequently work the front lines, picking up the early signals when families are in crisis, NASP has responded to the deepening recession with a full-court press designed to support their member psychologists. The organization recently administered an email survey to members to accurately assess the impact schools were feeling.

“We were flooded with more than 700 responses—far more than any of our other surveys have ever received,” says Kathy Cowan, director of marketing and communications for NASP. “What struck me was the time so many school psychologists took to fill out the open comments section.” She describes the responses as “pretty consistent in their intensity,” citing increases in homeless students and transient families, and the need for more basic services.

“Some schools are opening up their locker rooms for students and families to shower,” Cowan says. “And I’ve heard stories about school nurses taking food that is left over from staff meetings and handing it out to kids to take home.” Dr. McGrath adds that many schools also watch for signs such as the increased use of breakfast programs so that they can make certain that those programs are strong enough to meet the greater demand.

High on the list of concerns that Cowan is hearing from NASP members is the potential for the elimination of many school psychology positions, and the impact such cuts would have on schools. Because the law requires the development of individual education programs (IEPs) for all special needs students, she explains, the fear is that when districts lose psychologists, those who are left may have time only for IEPs, leaving the mental health needs of other students unmet.

“There is a palpable strain on staff and teachers,” Cowan says. “Schools are dealing with a growing number of suffering families while also coping with decreased resources in their districts, and often their own crises as well. With budgets being cut and positions being lost, job security is an issue for everyone.”

Marie is an adult whose life has been defined by severe developmental disabilities. Rische is a 2008 graduate of The Chicago School’s Applied Behavior Analysis (ABA) program who, as a student therapist, brought about significant and unexpected change in her client.

As an ABA intern, Jaime Rische successfully brought down communication barricades that had long stood between Marie and the rest of the world.

Admiring Marie’s shoes, her sparkly sunglasses, and her purplypink room décor contributed to Rische’s success. So did the unwavering interest, patience, and understanding that she showed her client, whom she treated as much like a friend as a patient. But it was her training as a behavior analyst, and her ability to put the lessons learned in class to practical and effective use that was the key to what Marie’s residential care staff term a “breakthrough.”

“We’re talking about people with significant limitations and, for Marie, Jaime was a difference maker,” Anthony DiVittorio, executive director of Blue Cap, the Blue Island agency that has cared for Marie for decades, says. “But the success goes beyond Marie. Our staff was so impressed with what Jaime was able to accomplish with the techniques she used that they have asked to be trained themselves so that they can use the same methods with other people they care for.”

The technique DiVittorio cites is the Picture Exchange Communication System (PECS), an intervention designed by a behavior analyst to help nonverbal clients communicate through the use of picture cards. Using PECS, Rische was able to teach Marie to make her needs and feelings known—a radical change from the behavior that had long been characteristic for her.

“Before I started working with her, Marie was without functional communication and intensely aggressive toward her surroundings and toward herself,” Rische says. “Human contact was a big problem; touching her could result in furniture being thrown or she would destroy the part of her skin that was touched.” She adds that when she initially reviewed Marie’s records, she found that frequent incidents of self injury had a been a pattern as far back as the ‘80s.

“It was the only way she knew to get attention,” Rische says.

Mental health experts say that mental retardation (MR) and selfinjury often go hand in hand, a correlation that is also noted in The Diagnostic and Statistical Manual of Mental Disorders. Evidence suggests that the behavior is particularly prevalent among nonverbal patients and is often a result of not having learned to identify or express difficult feelings in a healthy way.

For individuals like Marie— who spent her childhood in an institution—the lack of early intervention or experiences with positive interactions contributed to the solitary path her life would take. After completing a functional behavioral analysis, Rische was able to determine that the selfinjurious behaviors Marie used to get attention were, essentially, learned behaviors—behaviors that might have developed differently in another environment.

Today, infants identified with cognitive impairments receive immediate and intensive services designed to develop the individual’s potential to its fullest and to teach, among other things, the social skills that can help the person function as normally as possible. It is that level of early intervention that Marie missed out on, Rische says. But the sense of what might have been didn’t stop her from designing the program that would, as DiVittorio says, become a “difference maker in Marie’s life.”

That difference began with a relationship.

“I realized what Marie needed was a girlfriend; it was the kind of attention she had never had,” Rische says. She began by showing Marie that it could be fun to have a friend to sit with, to share a cup of coffee with, to be silly with. She complimented her clothes, brought her fun hats to wear, and danced to Beach Boys music with her. In a few weeks, Marie began seeking Rische out. Then, once PECS was introduced, Marie’s progress exploded. Armed with a book of picture cards held in place by Velcro, Marie learned to ask for coffee, to specify cream or sugar, and—for the first time in her life—to make verbal sounds such as “c-c-c” for “coffee.”

Our staff was so impressed with what Jaime was able to accomplish with the techniques she used that they have asked to be trained themselves so that they can use the same methods with other people they care for.

Developed a decade ago as a way of helping children with autism learn to communicate, PECS is widely used with children and adults with an array of communicative, cognitive, and physical disabilities. It has proven particularly valuable— a claim backed up by extensive research—in encouraging nonverbal patients to initiate conversation and to express their desires and feelings. Marie’s book, which Rische compiled based on PECS protocols, includes pictures that represent many of the things that are part of her everyday life: banana, Reese’s Pieces candy, chair, shoes, car, hug. It has been instrumental in bridging the communication gap between her and the staff who care for her.

The story of Rische’s success with Marie has not been met with surprise by faculty at The Chicago School. Breakthroughs of this type are what the field of applied behavior analysis is all about. Sometimes considered painstakingly laborious by those who are looking for quick fixes for complex behavior issues, the data—which meticulously tracks responses to minute changes in environmental stimuli—offers indisputable evidence of what works and what doesn’t work.

Marie is what Rische refers to as “a shining example” of the effectiveness that behavior analysis can have on those with other developmental disabilities. Born with severe cognitive impairments, she was institutionalized in early infancy, and remained in that setting until the deinstitutionalization movement of the late 1970s. At her current home, Blue Cap, she lives in a Community-Integrated Living Arrangement (CILA) group home, and attends an adult day services program that includes classes in daily living skills. She also works part time on an assembly line, sorting flashlight components and building supplies.

Rische and Marie reunited during a visit.

It was in the Blue Cap adult classroom, during her Chicago School internship, that Rische first encountered Marie. After observing her low frustration threshold, aggressive outbursts, and repeated self-injurious behavior, Rische proposed using her recently acquired ABA skills to work with Marie in a oneon- one setting.

DiVittorio, who had just assumed the executive directorship at the agency, was quick to take her up on it. A graduate of the University of Nevada-Reno ABA program, he understood what Rische wanted to do and believed she could bring about a positive change in Marie’s behavior.

“Before I came, many of the services provided here were basically day care,” he said. “Our board had expressed an interest in going in a more clinical direction. Jaime was one of those pockets of quality that we already had available to us—she had done great work in our adult classroom—so this was an opportunity to let her really make a difference.”

During the time Marie and Rische spent together—almost every day for close to a year—the accomplishments mounted. Marie abandoned her horror of being touched, came to love gaudy costume jewelry used to reinforce not harming herself, and learned to use her PECS book to order a hamburger and french fries at McDonald’s. Most importantly, she delighted in the friend she had in Rische—a relationship that, sadly, couldn’t last forever.

Rische graduated in May and, armed with a new master’s degree, moved to California. Blue Cap staff recount the parting, which they say tugged at a fair share of heartstrings. But the breakthrough had been made and, although DiVittorio acknowledges ups and downs in the wake of Rische’s departure, Marie now has a way to communicate. She and her PECS book are never far apart.

“The difference has been remarkable,” DiVittorio observes. “Behavior analysts are known for the data they collect but in this case, if I want data, all I need to do is look at Marie’s arms.”

The lingering scars that he references were still apparent when Rische returned from California recently for a visit with her old friend. But they are no longer the angry wounds that speak of freshly inflicted rage and frustration. Faded and healed, they are reminders that change can happen.