Working 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.
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.
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.