Monthly Archives: November 2013

Working with sexually abused children

Gregory K. Moffatt November 25, 2013

BearMateo (not his real name) sat on the floor in my office playroom. Each week in therapy, he routinely played with a small plastic doll and every time, without fail, he placed objects in the doll’s mouth. This day, however, he did something more aggressive. His eyes wide and his face full of rage, he took a Tinker Toy, an apparent phallic symbol, and repeatedly jammed it into the doll’s mouth. “He doesn’t want it in his mouth,” Mateo said into the air, “but he’s going to get it in there anyway!”

A male babysitter had sexually violated Mateo several months earlier. I’m confident, in part based on Mateo’s playroom behavior, that the babysitter had forced himself into Mateo’s mouth. Fellatio wasn’t the only violation forced upon Mateo, but it was the most brutal. Recovery for Mateo would take months.

Those sessions occurred more than 25 years ago. Mateo was one of the first seriously abused children to enter my private practice, and I’ve never forgotten him. Unfortunately, he represents only one in a very long line of abused children I have seen over a nearly three-decade career. In some ways, each child is different, responds to abuse differently and progresses at her or his own pace, but the stages of counseling with this population generally are predictable.

Stages of therapy with abused children 

Stage one: Trust. No matter how much parents tell me their children are shy or “won’t talk to a therapist,” I’ve never failed to gain these children’s trust within the first session or two, often within the first few minutes. More than once I’ve been shocked at how quickly children have divulged deeply hurtful and frightening information to me, almost as though it was ready to explode from them at the first opportunity that someone took to listen. Other times, however, it has not been so easy. Hundreds of children have come through my office doors, and I have learned to use the tools of my trade to create an environment of safety.

Play therapists have an advantage over more traditional counselors in these first visits. My office is full of toys, puppets, books, crayons and sandboxes, along with literally thousands of miniatures. As we begin, my first question is usually “Would you like to play for a while?” Only rarely have I come across a child who didn’t want to play.

I want to give the child as much control as possible throughout therapy, but it is especially important during these first sessions. A therapist I greatly respect taught me the phrase, “You can do about anything you want to in here. If there is something you can’t do, I’ll tell you.” I have used that opening line for years, and it has never failed me.

But children will test that statement. When I said this during Mateo’s first visit, he asked skeptically, “Can I dump all the toys out of the toy box?” He rested his hand on the rim of the large plastic tub that contained many of my toys.

“If you need to,” was my response. As I have learned to expect when such a question is posed, Mateo turned the box up on end and dumped everything out. I sat quietly and smiled at him. He smiled back. I had passed his first test for me.

Mateo called me Greg from our first session. I hadn’t earned my Ph.D. at the time, but even now, I don’t like children referring to me as “doctor.” That term is too easily equated with shots or unpleasant experiences. “Greg” is just fine with me when parents will allow it. That also helps begin to create a context of “us” rather than a view that the child is there to be “treated.”

I have to be very careful how I move when I’m with children such as Mateo. Sexually abused children do not interpret movement in the same way that other children do, especially when that abuse has been repeated over many weeks or months. What most children would regard as an innocuous touch may easily be interpreted by sexually abused children as an invitation or command for sex. In the case of physically abused children, they will flinch if I move too quickly to reach for my pen, scratch my ear or adjust my sitting position on the floor (something I have to do often as I get older). Flinching is an unconscious protective reaction that these children have learned. The quick fists of abusers have surprised them before, so these children learn to be vigilant for punches and backhands. The body remembers.

Stage two: Symptom reduction. Once I’ve built trust with the child, I can begin stage two. During this part of therapy, I want to accomplish two things. First, I want to reduce the negative symptoms that brought the child to my office in the first place. If he or she isn’t sleeping or eating, or is having trouble paying attention at school or getting along with siblings, I work with the child and guardian(s) to address these symptoms.

Mateo regularly acted out sexually. He masturbated in public. He exposed himself to other children on his school bus and in his classroom. Most troubling, he forcibly fondled other children, especially younger girls who were too small or too confused to say no. We had to address these behaviors immediately. I almost always use behavioral modification tools to intervene when behaviors are as serious as these.

The second thing I want to accomplish is to provide the child with skills to manage or prevent his or her issues. I worked with Mateo to recognize his urges and to develop ways to manage them. I have two recliners in my office — one adult sized and one child sized. These are the “thinking chairs.” Mateo and I sat in the thinking chairs, both of us staring at the ceiling.

“I’m wondering what we could do when our body parts feel funny,” I said, referring to the urge to masturbate.

“Maybe I could go to my room,” Mateo said, interestingly turning my use of “we” into “I.” Children are surprisingly intuitive and insightful when adults take the time to listen to them. Going to his room was a good idea — one of many that Mateo came up with during the course of our therapy. When the child discovers a solution, he or she is more likely to believe it will work and, hence, more likely to implement it.

Stage three: Facing demons. Abreaction is a term I learned from Lenore Terr, a writer and psychiatrist in San Francisco. Abreaction means that the child is reliving or replaying the abuse in therapy. We all do this in everyday life. When something significant happens to us, we have the need to talk about it —reliving it through conversation.

Imagine that you saw a car accident happen in front of you on the way to work. You would tell your workmates when you arrived. You would think about it during the day. You might call your spouse and relate the event. This would go on until you had “talked it out.”

Young children don’t have the vocabulary or cognitive ability to talk it out. Instead, they act it out in dramatic play, through the pictures they draw or in the activities they engage in in my sandbox. They literally replay their traumas.

When Mateo was forcing the Tinker Toy into the doll’s mouth, he was abreacting. He was abreacting when he fondled children on his school bus, and his masturbation was also a form of abreaction. Like an interested workmate or an understanding spouse listening to your story of the auto accident, I help children work through their stories over and over until they achieve a resolution.

One child in therapy with me abreacted to a perpetrator by repeatedly burying a little toy man in a wad of play dough each day that we worked together. In subsequent sessions, the child left more and more of the little man uncovered by the play dough. By our last session together, only the toy’s feet remained covered. “I see the man is almost free,” I said to the child. Confidently, the child smiled at me and said, “That’s OK, I can handle him.” This little boy had worked through the trauma of his abduction and abuse. His therapy was almost done.

Stage four: Wrapping up. Once symptoms have abated to a point where the child can cope, when he has the tools to deal with stressors in his life and the invasive thoughts and dreams that haunted him have faded away, the child is ready to work toward closure.

After 10 months of therapy, Mateo’s parents reported to me that his autoerotic behavior was under control and he rarely engaged in that behavior in environments where it was inappropriate. He was no longer exposing himself or talking sexually with other children, and he hadn’t touched another child since our first visit. His abreaction in therapy had trickled into almost nothing. His outbursts and temper tantrums were greatly reduced, and his parents now had the skills they needed to work with Mateo without my assistance. It was time to talk about closure.

Stage five: Termination. Saying goodbye to Mateo was hard for me. When growth happens as it should in therapy, it is rewarding and exciting. It is hard not to take ownership of it, but the truth is, Mateo was responsible for that growth, not me.

In the last session with each of the children I work with, the child gets to choose what we do. This allows the child to have control of his or her final hour with me and the work we have done together.

Mateo selected what many children subsequent to him have chosen. “I want to draw something,” he said.

I nodded but otherwise said nothing. Spilling crayons onto the floor in front of him, he worked intently, drawing on the paper while I watched. I was afraid to move because I didn’t want to break his concentration. When he finished, he took a deep breath, smiled at me and handed me his drawing. Two stick figures were holding hands, the sun bright in the upper part of the page and flowers standing like sentinels on either side of them. One figure looked like Mateo, who always drew himself wearing a baseball cap. The other figure was an adult.

“Tell me about your picture,” I said with interest. But I already knew what he was going to say. It was just what I had hoped for.

“This is me,” he said, pointing to the smaller figure with the ball cap. Then, pointing to the other figure, he added, “… and this is my mom.”

He was ready to go. There would be days in the future when Mateo’s abuse would still haunt him, but for now, he had worked through his abuse, his support system was in place, and it was time for me to say goodbye.

Conclusion

Kids like Mateo are the reason I chose counseling with children as my career path. During my residency and internships, I sat with adults, many of them in their 50s and 60s, while they shared unresolved traumas dating back to childhood. I thought it was tragic that decades earlier, they had been set on a path that permanently affected their lives. Those traumas had set a course for the careers they would choose, the people they would marry and how they would cope with life.

For almost all of these individuals, no one had been there to help them at the time of their trauma. If they had received intervention those many years earlier, their lives would have turned out very differently. My hope for children like Mateo is that the time they spend with me will address issues that, left untreated, could lead to years of dysfunctional relationships and unhealthy habits.

There is nothing more satisfying than working with a child like Mateo. Boys and girls bring their stories to me day after day. The first time they come into my office, they are often broken and fragmented. They sometimes stare at me with wide eyes, wondering if it is even possible to overcome the painful experiences that life has dealt them. Yet at the same time, they are very hopeful and willing to take a chance on me. Most of them leave as completely new creatures. Even though their experiences will always remain with them, I can have confidence that they will not be in a counselor’s office 40 years in the future, crying because of the abuse they suffered. That is something we can take care of now, and that is why each day I face the challenges of this population with courage and hope.

Click here to read Gregory K. Moffatt’s related article on complications related to working with sexually abused children. In the article, he discusses confidentiality and mandated reporting, hidden agendas, assessment versus therapy, evidence-based therapy, preparing for court and staying healthy as a counselor when working with this population.

****

 

Gregory K. Moffatt is a licensed professional counselor and professor of counseling and human services at Point University in Georgia. Contact him at Greg.Moffatt@point.edu.

Letters to the editor: ct@counseling.org

 

 

 

The birth of the neuro-counselor?

Sebastian Montes

Neuron-HeadLori Russell-Chapin was a quarter of the way through her scheduled 40 sessions of therapy with a 22-year-old college graduate with Asperger’s syndrome whose social shortcomings — understanding cues, relating with others — were hampering his relationship with his girlfriend and his parents.

As Russell-Chapin has done with hundreds of other clients the past four years, she put the young man into her neural feedback treatment program, which combines real-time brain-wave analysis with cognitive therapy. Ten sessions in, there was an astonishing breakthrough.

“I walked into the room one day,” Russell-Chapin says, “and he looked at me and said hello. And I said, ‘Hello!’ I know that doesn’t sound like much, but that’s big [for this client].”

Then, five sessions later, the client spontaneously asked Russell-Chapin how her daughter was handling her recent move, harkening back to a conversation the counselor and client had engaged in during an earlier session.

“I really almost fell off my chair,” says Russell-Chapin, a member of the American Counseling Association. “People start feeling more comfortable with who they are as a person if the central nervous system functions better. … It’s in behavioral checklists, it’s in empirical data. I can see it in my software — I can see their brain waves changing. People have the ability to regulate their brains.”

Four years — and hundreds of clients — after implementing neuroscientific technology into her counseling techniques, Russell-Chapin asserts that if counselors do not know what’s happening in their clients’ brains, they can’t possibly be effective.

“I’d been saying to graduate students for years, once we know more about the brain, it’s going to change how we do therapy,” says Russell-Chapin, a counselor educator at Bradley University and co-director of the Center for Collaborative Brain Research, a partnership between the school and a large medical center. “I really do think the brain is the final frontier, and we’re at this point where every day, we learn something new. If we as a profession want to go forward, we’ve got to go forward with the future, and this is where the future is. … The more I know [about the brain], the better counselor I’m going to be.”

Peering into the brain

The advances are staggering. Scientists and researchers are forging a seemingly endless stream of breakthroughs with the help of technologies that peer into the brain’s structure and function. And mental health practitioners are harnessing these discoveries through an array of new therapeutic models.

The torrent of technological innovation has already upended long-held notions of the brain’s slow but steady decay, furnishing empirical evidence that mental health professionals can bolster and even create new neural connections that may lead to targeted behavioral changes.

The development of functional MRI (fMRI) technology has opened a window into the brain’s neuronal network in real time, showing blood flow and activity in specific areas of the brain that are associated with specific functions. The discovery of neuroplasticity and neurogenesis — findings that the brain can change its neural structure and create entirely new neurons — has given rise to carefully engineered computer programs that claim to strengthen specific brain processes.

Although the study of the brain has long been the domain of psychiatrists and the more medically oriented end of the mental health spectrum, neuroscience has increasingly made its way into the counseling profession. With that has come the promise of heretofore unimaginable therapeutic possibilities that, for many counselors, have chipped away if not obliterated centuries-old beliefs about the distinction between the brain and the mind.

In growing numbers, adherents of the neuroscientific mindset are seizing upon an array of newer techniques to use in their clinics, including cognitive enhancement therapy and eye-movement desensitization and reprocessing. Many findings and techniques based in neuroscience are even being adapted into long-practiced counseling approaches such as cognitive behavior therapy.

A healthy portion of traditionalists and holdouts are uncomfortable with neuroscience’s growing influence in the practice of counseling, however, wary that it may steer the profession away from its humanistic roots.

Undaunted, neuroscience enthusiasts say that a generation of resistance is eroding as counselors begin to tap into the therapeutic power behind neuroscience findings and technologies. Their hope is that a new crop of counselors will emerge into the field already reared on curricula that place more emphasis on neuroscience.

The future is nigh

Around the turn of the millennium, Allen Ivey, a life member and fellow of ACA, started banging the neuroscience drum, calling on the counseling profession to embrace neuroscience under the mantra of “Therapeutic Lifestyle Changes” such as exercise, meditation and other brain-boosting behavior.

He and his wife, Mary Bradford Ivey, also an ACA fellow, continued that clarion call in a 2012 webinar hosted by ACA (see “Neuroscience: The Cutting Edge of Counseling’s Future” at counseling.org/continuing-education/webinars) and in their keynote at the ACA Conference in Cincinnati earlier this year.

The National Institute of Mental Health is increasingly turning to neuroscience as an alternative for moving away from the Diagnostic and Statistical Manual of Mental Disorders, Allen Ivey says. He predicts that action will eventually yield a totally new diagnostic approach.

“The brain-based paradigm is coming. … We’re going to have a very different way of handling mental health,” Ivey said in the 2012 ACA webinar. “

Ivey points to the understanding that negative stress leads to neuronal damage, which in turn impairs a person’s faculties for memory and emotional regulation, while traumatic experiences can negatively affect the individual even at the genetic level. He also points to evidence that positive empathic interventions — such as those provided by counselors — generate neural pathways, and he posits that a neuro-friendly mindset helps underpin multicultural awareness. These conclusions, among others drawn from neuroscience, have led Ivey to be boundlessly optimistic that counselors can — and should — tilt the balance of the nature-nurture dichotomy in their favor.

“There’s absolutely no excuse to give up on any client. … Our counseling can overcome genetics,” he says in the webinar, which stands as one of the most popular ever produced by ACA.

But others sound a note of caution on behalf of the humanist-oriented side of the counseling profession.

Matthew Lemberger-Truelove, president of the Association for Humanistic Counseling, a division of ACA, readily concedes that he marvels at some of the neurobiological work he sees his colleagues doing at the MIND (Mental Illness and Neuroscience Discovery) Institute at the University of New Mexico (UNM). But as those breakthroughs filter out, he says, counselors must be wary not to let them run roughshod over the profession’s humanistic principles.

“We’re way more sophisticated than what’s going on in one or two places inside of our body,” he says. “Instead, we’re a total unit that’s operating in a reflexive way with the world around us. You can’t just separate those. So, on the one hand, I agree with folks like Allen Ivey that neurology is incredibly important. But my problem is reducing it to the single problem, or even to a primary operation of what therapists need to do.”

Lemberger-Truelove, an ACA member and assistant professor of counselor education at UNM, worries that counselors are closing their critical eye in the hopes of finding a panacea with neuroscience.

“We are eager to find out things that will help our clients,” he says. “I think in so doing, we are going to — with good intentions — grab onto things that might be a straw man. An overreliance upon neurology without looking at the total human experience … is potentially naive. And, yes, I do see more counselors going that way, for the same reason we go to simple diagnostic algorithms, for the same reason we refer a client for psychotropic medications for the quick fix: because we as human beings want linear causation. There is a link between sensation and perception. But there’s also a difference between sensation and perception. In counseling, what we primarily deal with is a client’s perceptions. In some way, the thing that individuals sense certainly leads to their perception, but it’s not a perfect linear relationship. If counselors prioritize our profession as a profession about sensation, then we will change as a profession.”

Becoming neuro-minded 

Bill McHenry, associate professor of counseling at Texas A&M University-Texarkana, is a relative newcomer to neuroscience. He broke into the field a little more than a year ago after a long career focused largely on drug addiction. Looking back on his education, training and supervision, McHenry says it hinged on the belief that the brain people were born with was the brain they died with. It never broached the brain’s capacity to change or the brain-based aspects of the counseling process, he says.

Throughout his early career, McHenry felt limited by how little he understood of what was going on inside his clients’ brains. So, he started immersing himself in the emerging research and literature. That curiosity eventually led him to strike up a dialogue with one of his university colleagues, Angela Sikorski, a neuroscientist and assistant professor of psychology. To his surprise, he found that he could understand her explanations of the brain’s structural, chemical and neural processes, which he had assumed would be overly complex.

“That was certainly a watershed moment for me in my career. I still have all of my [counseling] techniques, all of my awareness and clinical intuition, but now I can be even more purposeful in what I’m doing,” McHenry says. “If you had asked me five years ago, eight years ago, 10 years ago, ‘Are you going to be this closely connected to the field of neuroscience as a counselor, and do you think that’s going to be important?’ I believe I would have said no. Because that’s not what we do in counseling. What we do in counseling is more artistic than regimented. As I’ve grown as a counselor, the better my skill set is, the more effective and efficient I am as a counselor. I would hope people would trust that this is a good thing for us. To know more about the brain is a good thing for counselors.”

As the first step in what can be an admittedly steep learning curve, McHenry suggests counselors immerse themselves in the neuroscience literature. This does not mean they necessarily need to stay up to date on every single breakthrough and innovation. Rather, he says, with a basic understanding of neuroscience principles and a few training sessions, counselors should soon be able to communicate those fundamentals to their clients.

“I’ve gone through cases that I worked years ago, and I thought, ‘Man, if I would have know that, I really could have educated my clients better,’” he says. “That’s the first piece to being more neuro-friendly for counselors is to be able to educate clients on potentially structural, chemical, biological and developmental issues within their particular brain. That information can be therapeutic in and of itself.”

The second step centers on the therapeutic process. McHenry now understands the value of counselors being able to focus their attention on what lobe of the client’s brain they’re working in and where there might be a neurological disconnect. “If I can discover those things, then I can go back and try to reignite or retrigger other parts of the brain,” he says.

The dialogue between McHenry and Sikorski led the duo to co-author A Counselor’s Introduction to Neuroscience, which was published in August. Their partnership is one that embodies the deepening ties between neuroscience and counseling.

Sikorski admits that neuroscience has its shortcomings, but she says the steady march of new findings is continually proving how much common ground counseling and neuroscience share. One of the most encouraging dimensions of the neurobiological breakthroughs, she says, is that researchers have unearthed surprising discoveries into the brain’s sensitivity to environmental factors, giving credence to the positive impacts of empathic listening and the counselor-client relationship.

“Do we know everything we need to know about how the brain works? The answer is no, absolutely not,” she says. “But the technology changes so much, and we learn so much more year by year, and one of the things it shows is that counseling and neuroscience are related, and they’re related in a really, really good way. The more we know about each, the more we contribute to our own specific discipline.”

A possible bridge

The past several years have seen the emergence of interpersonal neurobiology (IPNB) to the forefront of the mental health field, says Raissa Miller, a doctoral student at the University of North Texas. Many counselors see IPNB as a model that represents the possible middle ground between hard science and the art of counseling.

Pioneered by Dan Siegel, a clinical professor of psychiatry at the UCLA School of Medicine and executive director of the Mindsight Institute in California, IPNB seeks to foster an interdisciplinary view that encompasses the mind, body and brain as well as a person’s relationships with others. Under the catchphrase of “inspire each other to rewire,” IPNB draws from such disparate approaches as psychology, cognitive science, linguistics, chaos theory and anthropology to highlight how focus and personal relationships can change brain structure. It also gets at an understanding of the link between, for example, thoughts and feelings, or bodily sensation and logical processes.

IPNB, along with the writings of Bonnie Badenoch, particularly her landmark book Being a Brain-Wise Therapist, convinced Miller of the need to adopt a neuroscientific mindset as a counselor. An ACA member, Miller still has the audio recording of the first time she showed one of her clients a model of the brain to help the individual better understand stress level reactions. “It was shaky and probably sounded kind of funny, but I remember the client really lighting up and having an aha moment and releasing some of their self-blame,” says Miller, who was seeing clients in her private practice at the time.

Miller took Siegel’s 90-hour online course and participated in several IPNB workshops. She also trained with Badenoch in Dallas. Her next frontier is to study what happens not to clients within the IPNB framework, but to counselors themselves. Her dissertation is a qualitative phenomenological analysis of counseling students’ experience learning IPNB, and she presented a hypothetical IPNB-based curriculum at the Association for Counselor Education and Supervision Conference in October.

Miller believes IPNB can yield useful insights into the counseling experience, for example, by applying scientific terminology and understanding to counseling elements such as countertransference and the dynamic of empathy.

By taking that approach, she says, “it’s not just theoretical concepts anymore. It’s actual things going on in the brain. Anecdotally, what I hear is that it helps them [counseling students] understand themselves a lot better, which in counseling training is so important. Anything that helps counselors be more aware of their own internal world and understand the reactions they’re having with clients in the moment can also help them understand what’s going on with their clients and what really needs to be targeted for intervention. We are so grounded in the [client-counselor] relationship having a substantial impact on the mind, change and the whole counseling process. This helps us understand from a neuroscientific perspective why that information is critical.”

Immediate results

The neurological answer to a client’s problems can start as simply as learning to breathe.

Russell-Chapin still uses much of the same cognitive therapy she has used with clients throughout her career. The difference today is that she incorporates neurofeedback into the therapy to show clients how to control their skin temperature, breathe, exercise and sleep.

“People who come to me for neurofeedback have been to five or six therapists and they have had good therapy, but there’s still something missing. This is the piece that’s missing,” she says. “I’ve always believed counseling works, and we’ve known it works from the beginning of time. Behaviors change, so we can see people changing. Now we know what works, and we can see it with fMRIs. You can truly see pre- and posttest how we’ve built new neuronal pathways from doing therapy. So I’m still doing cognitive therapy, but now when my client comes to me and says, ‘Boy, am I feeling anxious’ or ‘Boy, I have this huge headache’ or ‘I am so depressed,’ I know exactly what part of the brain is activating.”

“I love doing this as a counselor,” she says. “Through the principles of operant and classical conditioning, I can help get their brain waves regulated again. It’s remarkable. The brain is so malleable that we can condition it just like we can condition any other muscle in our body.”

Ryan Melton, an ACA member and clinical training director of the Regional Research Institute at Portland State University, had his doubts. He didn’t think the array of computer games associated with cognitive enhancement therapy would work. He judged them to be too mundane and not engaging enough for clients to find worthwhile or useful.

But in the studies in which he has been involved, cognitive enhancement therapy has time and time again proved to be useful for clients with severe mental disorders who were consistently showing signs of neurocognitive deficits. Melton describes those neurocognitive deficits to his counseling students as “the invisible symptoms within invisible illnesses.”

Melton says cognitive enhancement therapy was developed and originally implemented more by psychologists. But the therapy has been making its way more and more into the counseling profession during the past few years. And he couldn’t be more excited.

“Because of some of our traditions [in the counseling profession], I think what happens … is that when we feel like the talking cure doesn’t work, then we’re kind of stuck,” Melton says. “There’s more that we can do, and when we focus on these neurocognitive deficits and the skills, the accommodations that can be done can be very simple.”

With dozens of clients, Melton has seen cognitive enhancement therapy’s video-game-based model leverage neuroplasticity to repair specific psychosocial and neurobiological deficits, including processing speed, executive function, working memory, social cognition and the like. The video games require clients to employ those specific faculties at certain times.

Melton reviews the results with each client. He talks through what cues the clients responded to, what they did well and what they struggled with, and how those cognitive decisions — be they failings or successes — translate into the clients’ day-to-day performance at work and in their personal lives.

By performing better on the games, the clients get instant feedback and find a sense of greater self-efficacy, Melton says. In addition, he says, clients show up more regularly for appointments and feel more invested in the process.

“It’s more immediately engaging. They see immediate benefits,” Melton says. “They feel — and probably there is — more science behind it than, say, cognitive behavioral therapy, even though CBT might be doing the same thing. The clients are really buying in [with cognitive enhancement therapy].”

Melton has weaved neuroscientific principles into every course he has taught in three years as a counselor educator at Portland State. “Once you get through that initial barrier of what [counseling students] think the profession can and can’t do, there’s absolutely an appetite for this kind of information,” he says.

Though he’d still like to see neuroscience more widespread across counseling curricula, he hopes its growing presence is creating a profession in which hostility toward neuroscience principles is a thing of the past. “I hope so. I think we need to grow as a profession,” Melton says. “Others might disagree with that, but I hope so.”

A leap of faith

Critics of neuroscience blast some of the techniques as lacking scientific justification and data to prove their effectiveness. Even counselors who are enthusiastic supporters of neuroscience generally remain guarded about its more dramatic claims.

Miller is encouraged by the developments she has witnessed within the IPNB framework, though she acknowledges that much of the research upon which IPNB is based lies largely outside her expertise.

The science “is emerging, and I think we have to be cautious. For any of the neuroscientists, it is easy to get ahead of themselves,” she says. “I feel like I am having to trust some of these neuroscientists and psychiatrists who are writing these books. I’m having to trust their interpretations. I’m having to trust that some of the implications and what they’re saying is true, which I guess is a little shaky, but I’ve not hesitated.”

Melton takes issue with how directly some practitioners draw conclusions from the neural activity they witness during sessions. He concedes there is a lot of room for the science to grow and become more precise.

“We do sometimes make too much of the fMRIs,” he says. “If we could diagnose using fMRIs or blood tests, we would do that. But we don’t, and we can’t. Even the [American Psychiatric Association] says we’re still 10 years away from that. Of course, I remember them saying that 10 years ago. It’s not just about what’s lighting up in our brain. Even when I talk to physicians, they say, ‘Oh, well they’re getting less blood flow to the dorsolateral prefrontal cortex’ or wherever, and I say, ‘What does that mean for the kind of day-to-day work [the client] faces?’ And they can only say, ‘Well, they’re getting less blood flow.’”

Still, neuroscience continues to entrench itself into what insurance providers and mental health organizations deem as best practices, Miller says. This leaves some counselors worried that other mental health professions are making big advances as a result of embracing neuroscience. They fear that if counseling doesn’t do the same, there will be dire consequences, especially if counselors aren’t at least conversant in neuroscience principles or able to express how those principles are relevant to — and supportive of — the counseling process.

“I kind of see us falling behind or maybe not being seen as legitimate, which I think is already sometimes a struggle — to not be seen as on the same playing field as other mental health professions,” Miller says. “This seems to be the emerging common language, so if we want to stay on the same footing as other mental health professionals, we would do well to integrate it. … The counseling profession has struggled to produce significant outcome studies showing that what we do is effective. If we can start using this language and show how what we do is effective and publish it more, I think it’s just going to strengthen the field.”

But faced with that argument, Lemberger-Truelove urges the counseling profession to stand its ground.

“For how long do we as counselors have to feel feelings of inferiority with our big brothers, the psychologists and psychiatrists?” he asks. “Let’s just do what we do well. I encourage other professions to chase that straw man because, in the end, that’s just not the philosophy of counseling. Counseling is really about appreciating the individual, their unique differences and how an individual can best manifest whatever unique difference they have. If we remain steadfast in the idea that we interact with clients’ perceptions of themselves and their world and the social systems under which they operate, then I think there will still be a place for us, and we won’t be competing with the different [mental health] professions. We’ll really be stalwarts. We’ll be the experts of how clients can exist in a very pragmatic, useful way.”

In that sense, the humanistic aspect that counseling brings to mental health is a crucial counterweight to the excitement of neuroscience, Melton says.

“We still know that we get our best outcomes when we establish a strong therapeutic alliance with our clients,” he says. “That’s one thing we know that’s almost necessary in treatment, regardless of our profession. It’s true in psychiatry and psychology and social work and counseling. So we still need that piece, even if our follow-up treatment is going to be a pill, cognitive behavioral therapy or cognitive enhancement therapy. That still needs to be there. Let’s not go one way or the other. Let’s stay in the middle with this, because that’s what we know.”

To contact the individuals interviewed for this article, email:

 

 

Research in counseling

By Cirecie West-Olatunji

CericieAs we move the discipline of counseling into a season of stability, increased professionalism and sustainability, we must place greater emphasis on research in counseling.

There are four primary reasons for this impetus. First, by prioritizing counseling research, we move forward as a discipline to our next developmental step — from the conceptual to the empirical. Second, there is a need for more empirical articles that reflect our pedagogical perspective. Third, as many counseling students have lamented, our discipline still lacks a sufficient number of research studies to provide a foundation for research projects. Finally, counseling research gives voice to our lived experiences as counselors and serves as a buffer against marginalization within the mental health research community.

During the past four decades, counselor educators have articulated the need for humanism and multicultural competence, among other ideals. Appropriately, many of the articles published in ACA journals have been conceptual in nature to explicate new constructs, approaches and paradigms. For example, most beginning counselors today have a clear understanding and appreciation for the complex issues presented when working with diverse clients. Moreover, the majority of our training programs have emphasized the relationship between counselor bias and clinical efficacy. Yet, it is time for us to provide evidence not only that the difference exists, but where and how it exists within the therapeutic relationship. More important, we need to know what interventions have been proved to effectively resolve or diminish obstacles to well-being. We should substantially increase the number of research articles in counseling journals to further our development as a profession and to ensure our place within mental health research.

In addition to increasing the number of empirical articles in counseling journals, we can become more intentional about founding our studies in the basic tenets of our profession. Research that reflects humanistic values such as empowerment, resilience, prevention and holism are sorely needed. Far too often, clinical research is deficit-oriented, marginalizing, hegemonic and limited by an emphasis on the intrapsychic experience. We need to serve as advocates for our clients by fostering more mindful research that reflects our unique disciplinary perspective.

In addition to being more intentional about how we frame our research, we need to increase the volume of research in counseling. I, for one, am tired of receiving papers from students (regardless of the given clinical area or topic) that cite every discipline except counseling. When I ask students why they failed to sufficiently cite counseling journals, they often reply there were few if any counseling citations for the chosen (or assigned) topic. Leaders in the counseling profession need to develop initiatives that encourage researchers to conduct and disseminate more research that informs those within and outside of our community about the value and utility of counseling.

Lastly, counselors must believe that by increasing research in counseling, we self-advocate and take social action against marginalization. Although there are those outside of our discipline who believe that counselors are not capable of girding the profession with sufficient analytical prowess and rigor, I disagree. With sufficient, sustained and concerted effort, we can collectively sponsor a campaign to improve and enhance the quality and quantity of counseling research.

As an organization, ACA is committed to this goal, as evidenced by the establishment of the Center for Counseling Practice, Policy and Research, under the direction of Will Stroble. The purpose of the center is to advance ACA’s strategic initiative focused on increasing counseling research and making it more accessible to practitioners. As Will continues to unfold the center’s projects, he will be soliciting input, assistance and support from the ACA membership. Please take time to reflect on how you can contribute to the campaign to increase research in counseling, dialogue with others about the possibilities and then take one concrete step. It matters.

Racial identity development and supervision

By Yegan Pillay

MaskThe demographic profile of the United States is undergoing rapid transformation as a result of factors such as immigration and the fertility/mortality rates among the various population groups. According to the 2008 Pew Research Center actuarial projections, the percentage of the White population will decline from approximately 67 percent to 47 percent between the years 2005 and 2050. Minority groups such Asians are projected to increase from 5 percent to 9 percent of the U.S. population during this time, while individuals residing in the United States but born outside the country will increase from 12 percent to 19 percent of the population. Hispanics are currently the largest minority group in the United States. By 2050, it is estimated that individuals of Hispanic or Latino origin will make up approximately 29 percent of the U.S. population.

After seeing these statistics, a question may pop into readers’ minds: What implications does the changing population landscape have for mental health professionals?

An obvious response is that mental health professionals will increasingly come into contact with clients who are racially and ethnically different from them. But what may miss our attention is the increased interaction between mental health counselors and supervisors who are racially and ethnically different.

Supervisors are fewer in number than counselors, which limits the choices that counselors have in selecting supervisors relative to the choices that clients have in selecting counselors. Moreover, counselors who work at agencies are usually assigned to a supervisor, which means they may have little or no choice regarding with whom they are paired. Supervision is provided by more experienced counselors, and the current cadre of experienced counselors is predominantly White. This means that as greater numbers of minority individuals become trained as mental health professionals, they will likely interface with supervisors who are racially different from them.

What information would be useful in helping the counseling profession to address this changing racial landscape? Greater attention has been paid to multiculturalism in the counseling literature during the past few decades. This was buoyed in part by the declaration in the 1990s that multiculturalism was the fourth force in psychotherapy (after psychoanalysis, behaviorism and humanism) and the publication of the article “Multicultural Counseling Competencies and Standards: A Call to the Profession” by Derald Wing Sue, Patricia Arredondo and Roderick J. McDavis in the Journal of Counseling & Development in 1992. At about the same time, racial identity development theory was being fine-tuned. This theory caught the attention of educators, researchers and practitioners who were heeding the call to explore effective strategies for enhancing the multicultural competency of counselors.

Racial identity development theory has since become a common feature in the course work for training mental health practitioners, particularly as a tool for developing multicultural competency. This article examines the tenets of racial identity development theory and its utility for providing practical strategies that can be integrated into the repertoire of supervisory techniques when the supervisor and supervisee are racially different.

Racial identity overview

Racial identity theory has its roots in the work of psychologist William E. Cross Jr., who documented his personal experience in scholarly publications such as The Negro to Black Conversion Experience in 1971 and Shades of Black: Diversity in African-American Identity in 1991. The mid-1980s and early 1990s can be considered the watershed period in racial identity development theory, thanks largely to Janet Helms, who expanded on Cross’ seminal work concerning racial identity with the publication of Black and White Racial Identity: Theory, Research and Practice. Helms’ work focused on Black racial identity development (BRID), Person of Color identity development (POCID) and White racial identity development (WRID) specifically from the perspective of social and political influences and the assertion that, as a society, the United States had not reached a post-racial status. Other scholars have expanded on and critiqued racial identity theory, but Helms’ work continues to be the most frequently cited in the literature.

The main premise of racial identity development theory is the evolution of an individual’s racial identity on a continuum that ranges from being oblivious to the impact that race has on everyday interactions to a heightened awareness of its impact. This continuum is depicted by four statuses in the BRID and POCID models and six statuses in the WRID model. In the initial development of racial identity theory, stages were used, but this was soon replaced by statuses, implying that racial identity development is not a linear process and that individuals can vacillate between phases of development. The four statuses in the BRID model are pre-encounter, encounter, immersion/emersion and integration/commitment. The POCID model is similar, with the four statuses being conformity, dissonance, immersion/emersion and integrative awareness. The six statuses in the WRID model are contact, disintegration, reintegration, pseudo-independence, immersion/emersion and autonomy.

From the perspective of the BRID and POCID models, a person’s racial identity development evolves from denigration of his or her own race and the idealization of the dominant racial group (the pre-encounter or conformity status) to a sense of belonging to one’s own racial group and an acceptance of others who may be racially different (integrative awareness status). In the same vein, the WRID model summarizes the White person’s racial identity evolution from a lack of awareness of racism and White privilege (contact status) to confronting racism and oppression and forming alliances with individuals who may be different racially (autonomy).

In these models, as individuals move from the beginning phases of racial identity development (pre-encounter, conformity, contact) to the more advanced phases (integrative awareness, autonomy), their multicultural competency skills are enhanced. For a comprehensive review of the statuses and racial identity theory, see the resources listed at the end of this article.

The intersection of supervision and racial identity

Supervision is a tripartite relationship between the supervisor, supervisee and client. In 1979, Janine Bernard developed the discrimination model and described a supervisor as taking on the roles of teacher, counselor and consultant in addition to being a gatekeeper, evaluator and the monitor of client well-being. In relation to racial identity development, various permutations are possible between the supervisor and supervisee, with each holding a similar or different racial identity status.

In 1994, Donelda Cook overlayered Helms’ racial identity development theory with the relationship between the supervisor and supervisee and described the dyads that formed as progressive, regressive and parallel. Progressive refers to when the person in power (the supervisor) is further along the racial identity development continuum than the supervisee. Regressive refers to a relationship in which the supervisee is further along in the racial identity continuum than the supervisor. Parallel refers to when the supervisor and supervisee are at similar racial identity statuses. The parallel relationship is further subdivided into parallel relationship (high) — when the supervisee and supervisor occupy similar identity statuses at the higher end of the racial identity development continuum — and parallel relationships (low) — when supervisors and supervisees occupy similar statuses at the lower end of the continuum.

The hypothetical case that follows highlights how these relationships may manifest in the supervisory dyad when examined through the lens of racial identity development.

Adán is a 29-year-old Puerto Rican male who recently qualified as a mental health professional. He completed his graduate work at a predominantly Hispanic university in New Mexico and accepted a counseling position at an agency in southeast Ohio. He chose to accept this position because the agency specializes in treating individuals diagnosed with type 2 diabetes mellitus (T2DM) and major depressive disorder (MDD). Adán’s desire is to gain the relevant experience so that he can return to his community in New Mexico where T2DM is on the rise among Hispanic groups.

Adán is assigned to Jimmy, a 55-year-old Caucasian who is an experienced supervisor and mental health professional. He has worked at the agency for more than 10 years. Adán and Jimmy meet weekly for clinical supervision and discuss Cynthia, among other clients. Cynthia is a 62-year-old Caucasian woman who has chronic T2DM and is diagnosed with MDD. Adán reports to Jimmy that he is frustrated with the client and does not think the sessions are going well, especially because Cynthia questioned his credentials in the prior session.

The key points from the perspective of progressive, regressive and parallel relationships that may occur between the supervisor, supervisee and client are:

Progressive relationship 

  • The supervisor is at an advanced phase of the racial identity development continuum and is more likely to examine the role that race is playing in the relationship between the counselor and the client. He addresses this in supervision.
  • The supervisor takes on the role of a teacher and educates the supervisee about racism and how this may manifest with certain clients. For example, he brings it to the supervisee’s attention that the client may perceive the supervisee as inept because of her prejudice or bias toward Hispanics.
  • Because the supervisee is at an earlier phase of racial identity development, he may be oblivious to how racial prejudice on the part of the client may be playing out in their therapeutic relationship.
  • Rather than viewing the impasse with the client from the perspective of the complexities of racial identity development, the supervisee may internalize the poor therapeutic alliance as being his fault, which may negatively affect his confidence as a beginning professional counselor.
  • The supervisee may look entirely to the supervisor for guidance — idealizing the supervisor on the basis of race — and may underestimate his own abilities, especially when working with Cynthia.
  • The supervisee may resist challenging the client’s lifestyle — which may be exacerbating her symptoms of depression — because of an inferior-superior complex. This could negatively influence the client in working toward her goals of treatment.

Regressive relationship

  • The supervisor in this relationship may be oblivious to White privilege and the role that racism may be playing in the supervisee’s relationship with the client.
  • If the supervisee brings up the issue of race (because he is more attuned to issues of racism than the supervisor), the supervisor may dismiss the importance of addressing race and attribute the conflict with the client to differences in age or gender.
  • The supervisor may construe the supervisee’s response as resistance, which may affect the objectivity of his formative evaluation of the supervisee.
  • If the supervisee interprets the client’s perception of his lack of competence to racism, he may become further frustrated by the dismissive posture of the supervisor.
  • Alliance and rapport with the supervisor may be adversely affected, which may in turn compromise client welfare.

Parallel relationship (high)

  • Both the supervisor and the supervisee are aware of the role that race may be playing and its effect on the therapeutic relationship.
  • The supervisor and the supervisee explore strategies that the supervisee can use to address the impasse with the client.
  • Client welfare is enhanced when all facets of the client’s function are considered in the conceptualization of the client’s presenting issues.

 

Parallel relationship (low)

  • Both the supervisor and the supervisee may be oblivious to the influence that race is having on the therapeutic alliance.
  • The poor rapport between the counselor and the client may be attributed to other factors such as age or gender, and the “incompetence” alluded to by the client will remain unaddressed.
  • Client care may be compromised
  • if the client is stuck on the notion that the supervisee is incompetent because of his race.

Practical suggestions 

Supervisors and supervisees can use the following practical steps to enhance the supervision experience. These suggestions also intersect with the three tenets of multicultural competencies — namely awareness, knowledge and skill — advocated by Sue, Arredondo and McDavis.

  • Supervisors and supervisees would benefit from understanding where they are located on the racial identity development continuum because this information may shed light on the dynamics of the supervisory relationship. Excellent resources for racial identity assessments can be accessed through the Institute for the Study and Promotion of Race and Culture (see list of resources at the end of this article).
  • An important step in understanding racial identity development is recognizing that racial identity in the United States is a sociopolitical construct influenced by power and dominance. By familiarizing themselves with the history of race in the United States, supervisors and supervisees can increase their awareness of privilege and/or dominance as it relates to their specific racial group affiliation in the context of the broader racial landscape. This will contribute to moving from a state of naïveté about the influence of race on interpersonal interaction to actively exploring the influence of race, especially if one is situated at the beginning phases of racial identity development.
  • In a progressive relationship, the supervisor can take on the role of teacher/consultant/counselor to aid supervisees in becoming aware of and confronting how their racial identity may be influencing their efficacy with clients. In the hypothetical case of Adán discussed earlier, it would be important for the supervisor and Adán to explore the role of racial identity and whether Adán’s internalized “historical racial baggage” may be projected as “frustration” with the client.
  • Given the power dynamics that exist in the supervisor-supervisee relationship, regressive relationships can be trickier to navigate. This is especially true because the supervisor is the “gatekeeper” who plays an evaluative role in determining whether the supervisee meets a specific set of professional standards. In the case of Adán, if the supervisor becomes aware (say by taking a self-assessment) that he is at the beginning stages of racial identity development, then an important step would be for the supervisor to become knowledgeable about the race-influenced experience of Hispanics in the United States. Naïveté or obliviousness of the experiences of others on the part of individuals from the dominant culture is often attributable to a lack of contact with individuals who are racially or ethnically different. Contact is one of the most effective tools in tackling prejudice and bias toward others. In Adán’s situation, Jimmy (the supervisor) might temporarily immerse himself in the Hispanic culture to get a sense of their day-to-day experiences and become familiar with their cultural practices and norms. This might be a challenge in southeast Ohio, where Jimmy is a supervisor, because there are fewer Hispanics in the region. However, multiple resources are available on the Internet. For example, videos such as A Class Apart and Chicano! PBS Documentary — Fighting for Political Power can be viewed on YouTube and are useful alternatives in the absence of opportunities for actual immersion experiences.
  • The supervisee in a regressive supervisory relationship can also assume the role of cultural educator/consultant if the supervisor is not addressing issues of race or ethnicity. Given the aforementioned power dynamics, this can be a challenging endeavor for the supervisee, but it is important to place the issue of race on the supervision agenda by broaching the topic. For example, Adán could ask Jimmy, “Do you think that my Hispanic heritage is playing a role in my frustration with the client?” Or in more established supervisory relationships, supervisees who are further along in their racial identity development might articulate their perspective on the role of possible racism in the relationship with the client. These strategies will encourage the supervisor to examine an aspect of the counselor-client interaction that has not been previously considered. These actions may also serve as a catalyst for the supervisor to begin paying attention to variables that are race/ethnicity based in other supervisory relationships.

Conclusions and resources

Racial issues are an integral facet of the social fabric of the United States, and as demographic actuarial data suggest, it behooves us as mental health professionals to attend to race and the accompanying issues surrounding racial identity in counseling and supervisory relationships. The supervisor-supervisee-client relationship is complex. A variety of factors can affect the quality of the supervisor-supervisee relationship and, concomitantly, the client’s well-being. Moreover, the racial identity development of the supervisor, the supervisee and the client can take on various dyadic permutations, but these may be overlooked as factors influencing the supervisory relationship and the therapeutic alliance.

Racial identity development is not necessarily an issue with all supervisor-supervisee-client dyads, but it remains an important consideration, especially when supervisors, supervisees and clients are different racially. It is highly recommended that supervisors and supervisees become aware of where they are located on the racial identity continuum. Awareness of self and knowledge of others can serve mental health professionals well in advancing our skills with clients and adding to our toolbox of multicultural competencies.

I have found the following resources to be particularly helpful:

  • A Race Is a Nice Thing to Have: A Guide to Being A White Person or Understanding the White Persons in Your Life by Janet E. Helms
  • Handbook of Multicultural Counseling edited by Joseph G. Ponterotto, J. Manuel Casas, Lisa A. Suzuki and Charlene M. Alexander: A good resource in general that includes a chapter by Helms updating her WRID and POCID models.
  • The Institute for the Study and Promotion of Race and Culture (bc.edu/content/bc/schools/lsoe/isprc.html) is an excellent resource. The institute is located at Boston College under the direction of Helms and offers a wide range of resources and links for assessment, trainings, conferences and other tools related to racial identity development.

Knowledge Share articles are adapted from sessions presented at American Counseling Associations conferences.

 

****

Yegan Pillay is a licensed professional clinical counselor with supervisor endorsement from the Ohio Counselor, Social Worker and Marriage & Family Therapist Board. He is an associate professor in the Department of Counseling and Higher Education at Ohio University-Athens. He has spent several years nationally and internationally as a counselor educator, researcher and clinical mental health professional. Contact him at pillay@ohio.edu.

Letters to the editor: ct@counseling.org

 

Complications when working with sexually abused children

Gregory K. Moffatt November 21, 2013

sexually-abused-childrenWorking with children who have been sexually abused has taught me many things. While some children progress very quickly, I have learned to have patience with the children whose recovery comes more slowly. I’ve learned to be careful in taking notes, how to spot parents or guardians who are trying to manipulate me, and how to prepare for court. Working with physically and sexually abused children isn’t easy. There are many things about therapy with this population that I wish I’d been taught in graduate school, but instead I had to learn through experience.

Confidentiality and mandated reporting

Fortunately for me, Mateo’s perpetrator had already been arrested and child protective services had been involved before Mateo came to see me. But limits of confidentiality due to mandated reporting still remained. My records still could have been subpoenaed and I could have been called to court. I had to be very careful.

I make the limits of confidentiality clear to my clients’ parents and guardians, but it is challenging to help the child understand mandated reporting, court-ordered disclosure or similar issues that would require me to talk about his or her personal issues with others. Further complicating this puzzle is the inclusion of guardians ad litem and social workers to whom I occasionally must also report. Yet it is imperative for the child to understand that I cannot always keep his or her secrets. When I see that a child is about to disclose something I might have to share with someone else, I often have to remind the child about my obligations. “Remember I told you that sometimes I have to tell people what you tell me?” I remind the child. “I think you might be about to tell me something like that, so I wanted to remind you so you could choose whether or not you want to say it.”

Even when I don’t have to worry about disclosing issues to the court or to child protective services, I still must contend with the many people in the child’s life who want to know what is going on in therapy. Mateo’s biological mother routinely brought him to therapy, but a grandmother, an aunt and his father also occasionally brought him in. Access to a child’s records/therapy progress legally and ethically belongs to the custodial parent or parents, but this can be a challenging dilemma. Grandparents, stepparents, siblings, stepsiblings, live-in girlfriends or boyfriends, and even neighbors are among the people who have brought children to my clinical office or who have called and requested information about a session.

It can be challenging to maintain confidentiality for the child while partnering with parents, guardians or caregivers. I want and need parental cooperation, but I am also bound by ethics and by the law regarding what I can say to whom. One child I saw off and on for almost a decade was not in the legal custody of his grandparents for most of that time, even though the child had lived with them since birth and his mother was almost completely absent from his life. So, should I have taken the grandparents’ payment but refused to discuss therapy with them? I don’t think so.

Hidden agendas

Working with abused children is complicated enough by itself. We have to consider developmental issues at the time of the trauma, who the perpetrator was, whether it was a single event or ritualistic abuse, the health of the child’s support system/family, and the coping skills and problem-solving set the child has at his or her disposal. But that isn’t all we have to think about as therapists.

Parents, especially those who are divorcing or battling for custody, often have hidden agendas when they bring their children to me. “I hope my husband didn’t do anything to my daughter,” I’ve often heard, “but I’m worried that he might have abused her.” Sometimes this statement comes from parents who legitimately do have this concern. Other times, the parent is attempting to play me, hoping I’ll find something that might imply abuse so that he or she can use that information against the spouse in a custody hearing. On occasion, the parent’s sole purpose was to have the accusation/intervention on record for when she or he took a custody request to a judge. My intake forms specifically ask about marital status, and I am very cautious when divorcing parents bring “concerns” of potential abuse that just happened to pop up after a decision to divorce.

Assessment versus therapy

As a young therapist, it took me awhile to realize there was a difference between assessment and therapy. In those days, I approached all children the same. I was originally trained as a person-centered therapist, and I had very little preparation in my graduate work in assessment. I was taught that what happened outside my office didn’t concern me. My job was to help the child achieve healing, so I began therapy with the first session. Imagine my embarrassment the first time I encountered the court system without a clear assessment.

The assessment is the first step in determining, as a mandated reporter, if I need to call child protective services. I have to address all evidence that points toward abuse. I have to address all evidence that points away from it as well. If I am called into court, I can be certain a competent attorney will leave no stone unturned to exonerate his or her client. Likewise, I don’t want an innocent person going to jail because I didn’t do a thorough assessment.

If a case has already entered the court system or been adjudicated, as was true for Mateo, I can relax a little and move more quickly into therapy, but assessment is still important. I have to address developmental issues. Understanding the child’s social, physical, emotional and cognitive development plays a key role in interpreting the child’s behavior. A symptom that may suggest sexual abuse at one developmental age may not be an indicator at another and vice versa. For example, very young children rarely make up stories about sexual abuse. They may be coached into saying things that imply sexual abuse, but they almost never spontaneously make up explicit stories of sexual maltreatment. On the other hand, prepubescent or pubescent children might. They have the cognitive ability to know about sex and its meanings and to use such skills to deliberately hurt a foster parent, guardian or parent. Developmental age, coping strategies and problem-solving abilities have to be noted before I can set forth an appropriate treatment plan.

Evidence-based therapy

In the early 1980s, nobody talked about evidence-based theory. It was assumed that if one was good enough to be recognized by the court as an expert witness, one must know what he or she was talking about. No more.

Whether I am assessing a child or doing therapy, the processes have to be based on something other than “I think it works.” I resisted this transition at first. After all, I’d worked with hundreds of children. Hadn’t I seen their progress?

But now I understand much better the importance of evidence-based approaches. Whether I am assessing the child or engaging in therapy, it is my responsibility to use approaches that are shown to be valid rather than simply doing what feels right to me. Not only is this more defensible in court, it is also the ethically appropriate thing to do.

Preparing for court

When I began working with children shortly after completing graduate studies, it was believed that court testimony could further traumatize a child. Therapists, lawyers and judges alike worked hard to avoid having the child appear in the courtroom. But research, as well as my own experience, has proved those ideas to be flawed.

Court can be traumatizing, but more often than not, children are empowered by the opportunity to go to court. They can fearlessly sit in a witness box, testify in their own childlike language and leave the courtroom feeling as though they have taken control of their lives. Defense attorneys are reluctant to badger young children, and their testimonies can be powerful. Therapeutically, it is equally powerful when a child faces his perpetrator and comes away knowing the perpetrator is going to jail.

Preparing a child for court often involves setting up my office as a courtroom. Children usually know nothing of judges, juries, court recorders or attorneys, so we practice playing court in different roles. This role-playing teaches the child what to expect and demystifies the courtroom. I often work with the child’s attorney as we prepare for court. I cannot prepare the child’s answers to likely questions, but I can prepare the child for the questions he or she might expect. “Just tell the truth and answer the questions,” I routinely say. “You are not in trouble, but the judge needs to hear from you.”

Prior to court, case notes need to be reviewed. Anything that will be used in depositions or provided to the court needs to be clear, concise and in objective, clinical language. I generally avoid writing down anything that isn’t necessary because if it isn’t written down, it cannot be subpoenaed. For my own testimony in court or depositions, one rule I live by comes from that old line in Dragnet — “Just the facts.” While I have my own agenda and hopes for the outcome of trial, the courtroom is no place for grandstanding, soapboxes or emotion. I answer questions as concisely as I can, I don’t speculate, and I never volunteer information. Even though it sometimes fails, I trust the legal system to do its job, and I do mine.

Staying healthy when working with sexually abused children

The hardest part of working with abused children, at least for me, is not the sad stories. I’ve heard them a thousand times, and a precious little face is attached to each story. It would seem that this work would eventually take its toll. But rather than wearing me down, working with these children is empowering for me. I am helping to make their lives better. I also cope with working with traumatized children by helping to empower them. I teach them skills they need to survive their troubled lives. I help them find ways to solve their problems, and I help their parents work with them more effectively.

What is hardest for me is when I am totally defeated by the court, social services or the parents of the children I work with. When I’ve exhausted all of my resources and cannot do more, I am most discouraged. At times like these, I simply have to remember the sad truth that I cannot save everyone.

To help the children in my practice, I have to take care of myself. It is imperative to maintain a good diet, exercise regularly and get enough rest. I cannot be what these children need me to be if I am tired, lethargic or burned-out. I find plenty of time to play and to disengage from life at the office. I take care of my health, I find time to laugh and refocus on the “normal” world, and I don’t let myself become jaded. I recognize that there are thousands of wonderful parents in the world. I can separate myself from my work because I’ve learned to put my work into compartments that I can open and close at will.

I have resisted texting, giving out my personal cell phone number and engaging in social media. I have to disengage from people with some regularity or I can’t rest. When I am at home watching a movie or reading a book, I am fully at home. I am not like many of my colleagues who feel the need to check email every five minutes or look at every text message that chimes in, no matter what activity, meal or conversation it might interrupt. Our culture has made almost any trivial communication an emergency that demands immediate attention. Emergencies happen, but they are relatively rare. When real emergencies happen, I am accessible, but otherwise, my time away from the office is for me and my family.

*****

For more on this topic, read Gregory K. Moffatt’s companion article, “Working with sexually abused children,” which appears in the December issue of Counseling Today.

Gregory K. Moffatt is a licensed professional counselor and professor of counseling and human services at Point University in Georgia. Contact him at Greg.Moffatt@point.edu.