Tag Archives: abuse

What’s left unsaid

By Lindsey Phillips January 3, 2019

A child discloses that her grandfather has been sexually abusing her, and the mother’s response is shock that his abuse didn’t stop with her when she was a child. This scene is not uncommon for Molly VanDuser, the president and clinical director of Peace of Mind, an outpatient counseling and trauma treatment center in North Carolina. As she explains, adult survivors of child sexual abuse often assume that the offender has changed or is too old to engage in such actions again. So, the abuse persists.

Concetta Holmes, the clinical director of the Child Protection Center in Sarasota, Florida, has treated clients with similar intergenerational abuse stories. “In that unresolved trauma … what has happened is now a culture of silence around sexual violence that is ingrained in the family,” she says. “That [affects] things like your feelings of safety, security [and] trustworthiness, and it reinforces that you should stay with people who hurt you.”

Kimberly Frazier, an associate professor in the Department of Clinical Rehabilitation and Counseling at Louisiana State University’s Health Sciences Center, acknowledges that people often don’t want to think or talk about child sexual abuse, but that doesn’t stop it from happening. The nonprofit Darkness to Light reported in 2013 that approximately 1 in 10 children will be sexually abused before they turn 18.

Because of the culture of silence that surrounds child sexual abuse, it is safe to assume that the true number is even higher. Cases of child sexual abuse often continue for years because the abuse is built on a foundation of secrets and fear, Frazier points out. Survivors frequently fear what will happen to them (or to others) if they tell, or the shame they feel about the abuse deters them from disclosing.

Societal norms can also diminish a survivor’s likelihood of disclosing. For example, society has for decades implicitly sanctioned sexual interactions between boys who are minors and adult woman, but it is still abuse, says Anna Viviani, an associate professor of counseling and director of the clinical mental health counseling and counselor education programs at Indiana State University. Holmes adds that gender stereotypes such as this can cause boys to feel as though they shouldn’t be or weren’t affected by sexual abuse, which is not the case.

“I think the biggest fallacy [counselors have] is that [child sexual abuse] is going to impact people from a particular demographic more than another,” Viviani says. “Childhood sexual abuse cuts across every demographic. I think the sooner we can accept that, the sooner we’re going to be better at identifying clients when they have this issue in their history.”

Putting on a detective hat

Identifying signs of child sexual abuse is neither easy nor straightforward. Part of the difficulty lies in the fact that the signs are not clear-cut, says VanDuser, a licensed professional counselor (LPC) and an American Counseling Association member. Regressive behaviors such as bed-wetting can indicate abuse, but they might also be the result of other changes such as a recent move, a new baby in the family or a military parent deploying, she explains.

VanDuser also warns that child sexual abuse is insidious because a lot goes on before the offender actually touches the child. “Childhood sexual abuse sometimes leaves no physical wounds to identify,” she says. Some examples of noncontact abuse include peeping in the window at the child, making a child watch pornography or encouraging a child to sit on one’s lap and play the “tickle game.” Such activities are part of the grooming process — the way that offenders build trust and gain access to the child.

In addition to physical signs such as bladder and vaginal infections, changes in eating habits, and stomachaches, survivors of child sexual abuse also demonstrate behavioral and emotional changes. One major warning sign is if the child displays a more advanced knowledge of sex than one would expect at the child’s developmental stage, VanDuser says.

Other possible behavioral signs include not wanting to be alone with a certain person (e.g., stepfather, babysitter), becoming clingy with a nonoffending caregiver, not wanting to remove clothing to change or bathe, being afraid of being alone at night, having nightmares or having difficulty concentrating. In general, counselors should look for behaviors that are out of character for that particular child, VanDuser advises.

Viviani, a licensed clinical professional counselor and an ACA member, also finds that people who have experienced child sexual abuse have higher rates of depression, anxiety, panic disorders and posttraumatic stress disorders.

Because the signs of child sexual abuse are rarely clear-cut, counselors must be good investigators, Viviani argues. In her experience, adult survivors present with an array of symptoms, including health concerns, relationship problems and gaps in memory, so counselors have to look for patterns to discover the underlying issue.

If counselors notice any of these signs, VanDuser recommends asking the client, “When did this problem (e.g., bed-wetting, cutting, nightmares, acting out in school) begin?” Counselors can then follow up and ask, “What else was going on at that time?” The answers to these questions often reveal the underlying issue, she notes. For example, if the client responds that his or her depression or vigilance to the environment began around age 12, VanDuser says she will dig deeper into the client’s family relationships.

Frazier, an LPC and a member of ACA, suggests that counselors can also look for patterns in a child’s drawing — for example, what colors they use, how intensely they draw with certain colors, or if they scratch out certain people or choose not to include someone — or in the choices children make with activities such as feeling faces cards (cards that depict different emotional facial expressions). When Frazier asked one of her clients who had come to counseling because of suspected sexual abuse to select from the feeling face cards, she noticed the client consistently picked cards with people wearing glasses. Frazier later discovered that the child’s abuser wore glasses.

For Frazier, becoming a detective also involves going outside of the office to observe the child in different spaces, such as in school, in day care or at the park. Frazier includes the possibility of outside observations in her consent form, so the child’s parent or guardian agrees to it beforehand. She advises that counselors should take note of whether the child’s behavior is consistent across all of these spaces or whether there are changes from home to school, for example. In addition, she suggests asking the parents or guardians follow-up questions about how the child’s behavior has changed (e.g., Has the child lost the joy of playing his or her favorite sport? Is the child withdrawn? Is the child fighting?).

Speaking a child’s language

Young children may not have the words or cognitive development to tell counselors about the abuse they have been subjected to. Instead, these children may engage in traumatic play, such as having monsters in the sand tray eat each other or being in a frenzied state and drawing aggressive pictures, VanDuser says.

“One of the most important things for clinicians to remember when they’re working with kids and abuse is that it’s really critical to be working within the languages that children speak,” says Holmes, a licensed clinical social worker and a nationally credentialed advocate through the National Organization for Victim Assistance. “Children speak through a variety of different languages that aren’t just verbal. They speak through play. They speak through art, through writing [and] through movement, so it becomes really important that clinicians get creative in using evidence-based practices and different modalities to talk with children through their language. … Talking in a child’s language allows them to feel like the topic at hand is less overwhelming and less scary.”

For example, children can use Legos to build a wall of their emotions, Holmes says, with counselors instructing clients to pick colors to represent different emotions. If orange represents sadness and red represents frustration and 90 percent of the child’s wall contains orange and red Legos, then the counselor gets a better visualization of what emotions are inside the child, she says.

Next, counselors could ask clients what it would take to remove a red brick of frustration or what their ideal wall would look like, such as one that contains more bricks representing happiness or peace. Counselors can also ask these clients to rebuild their Lego walls throughout therapy to see how their emotions are changing, Holmes says. This method is easier than asking children if their anger has decreased and by how much, she adds.

Frazier, past president of the Association for Multicultural Counseling and Development, a division of ACA, also finds that working with children keeps counselors on their toes. Children are honest and will admit if they do not like an intervention, so counselors have to be ready to shift strategies quickly, she says. For this reason, counselors need to have a wide range of creative approaches in their counseling bag. She recommends drawing supplies, play school or kitchen sets, play dough and sand trays.

With sand trays, Frazier likes to provide dinosaurs and other nonhuman figurines for children to play with because it helps them not to feel constrained or limited. This allows them to freely let a dinosaur or car represent a particular person or idea, she explains.

Frazier also recommends the “Popsicle family” intervention, in which children decorate Popsicle sticks to represent their family members and support systems. This exercise provides insight into family dynamics (who is included in the family and who isn’t) and allows children to describe and interact with these “people” like they would with Barbie dolls, she says.

Frazier advises counselors to keep culturally and developmentally appropriate materials on hand. For example, they should have big crayons for young children with limited fine motor skills, and they should have various shades of crayons, markers, pencils and construction paper so children can easily create what they want.

Being multiculturally competent goes beyond ethnicity, Frazier points out. Counselors should understand the culture the child grew up in and the culture of the child’s current locality because what is considered “normal” in one city or area might differ from another, she says. For example, in New Orleans, where she lives, people regularly have “adopted” family members. So, if a child from New Orleans were creating his or her Popsicle family, it wouldn’t be strange to see the child include several people outside of his or her immediate family and refer to them as “cousin” or “aunt,” even if they aren’t blood relatives.

Thus, Frazier stresses the importance of counselors immersing themselves in the worldview of their child clients. “You can’t be a person who works with kids and not know all the shows and the stuff that’s happening with that particular age group, the music, the things that are on trend and the things they’re talking about,” Frazier says. “Otherwise, you’ll always be behind trying to ask them, ‘What does that mean?’”

With adolescents, Holmes finds narrative therapy to be particularly effective, and she often incorporates art and interview techniques into the process. For example, the counselor could ask the client to draw a picture of an emotion that he or she feels, such as anger. Next, the client would give this emotion a name and create a short biography about it. For example, how was anger born? How did it grow up to be who it is? What fuels it? Why does it hang around?

Next, Holmes says, the counselor and client could discuss the questions the client would ask this emotion if it had its own voice. Then, the client could interview the initial picture of the emotion and use his or her own voice to answer the questions as the emotion would. The answers provide insight into the emotional distress the client is feeling, Holmes explains.

Frazier will do ad-lib word games with older children, who are often more verbal. While clients fill in the blanks to create their own stories, she looks for themes (e.g., gloomy story) or the child’s response to the word game (e.g., eager, withdrawn). 

Long-lasting effects

Unfortunately, the effects of child sexual abuse don’t end with childhood or even with counseling. “Children revisit their trauma at almost every age and stage of development, which is every two to three years,” Holmes notes. “That might not mean they need counseling each and every time, but they find new meaning in it or they find they have new questions … or new emotions about it.”

Viviani, VanDuser and Frazier agree that recovery is a lifelong process. As survivors age, they will have sexual encounters, get married, become pregnant or have their child reach the age they were when the abuse occurred. These events can all become trigger points for a flood of new physical and emotional symptoms related to the child sexual abuse, Viviani says.

Often, an issue separate from the abuse causes adult survivors to seek counseling. In fact, VanDuser says she rarely gets an adult who discloses child sexual abuse as the presenting issue. Instead, she finds adult clients are more likely to come in because their own child is having behavioral problems or because they’re feeling depressed or anxious, they’re having nightmares or they’re married and have no interest in sex.

Adults survivors often experience long-term physical ailments. According to Viviani, who presented on this topic at the ACA 2018 Conference & Expo in Atlanta, some of the ailments include diabetes, fibromyalgia and chronic pain syndromes, pelvic pain, sexual difficulties, headaches, substance use disorders, eating disorders, cardiovascular problems, hypertension and gastrointestinal problems.

Another long-term issue for survivors is difficulty forming healthy relationships. Because child sexual abuse alters boundaries, survivors may not realize when something is odd or abusive in a relationship, VanDuser says. For example, if an adult survivor is in a relationship with someone who is overly jealous and possessive, he or she may mistakenly translate that jealously into a sign of love.

Child sexual abuse can also affect decision-making as an adult around careers, housing, personal activities and sexual intimacy, Viviani notes. For example, one of her clients wanted to attend a Bible study group but didn’t feel safe being in a smaller group where a man might pay attention to her. In addition, Viviani finds that adult survivors sometimes choose careers they are not interested in just because those careers provide a safe environment with no triggers.

To help adult clients make sense of the abuse they suffered as children and move forward, Viviani often uses meaning-making activities and mindfulness techniques. She suggests that counselors help these clients find a way to do something purposeful with their history of abuse, whether that involves sharing their story with a testimony at church, volunteering for a mental health association or participating in a walk/run to raise awareness of suicide prevention.

Finding self-compassion

Survivors of child sexual abuse often blame themselves for the abuse or the aftermath once the abuse is revealed, especially if it results in the offender leaving the family, the family losing its home or the family’s income dropping, VanDuser says. One of her clients even confessed to thinking that she somehow triggered her child sexual abuse from her stepfather.

“Sometimes the worst part is the dread [when the child knows the sexual abuse is] coming eventually. So, sometimes a teenager will actually initiate it to get it over with because the only time they feel relief is after it’s done,” VanDuser explains. “Then they know for a while that they won’t be bothered again.”

Counselors often need to shine a light on survivors’ cognitive distortions to help them work through their guilt and shame, VanDuser says. She tries to help clients understand that the sexual abuse was not their fault by changing their perspective. For example, she will take a client to a park where there are children close to the age the survivor was when the abuse happened. She’ll point to one of the children playing and ask, “What could the child really do?” This simple question often helps clients realize that they couldn’t have done anything to prevent the abuse, VanDuser says.

Viviani takes a similar approach by talking with clients in the third person about their expectations of what a child would developmentally be able to do in a similar situation. She asks clients if they would blame another child (their grandchild or niece, for example) for being sexually abused. Then she asks why they blame themselves for what happened to them because they were also just children at the time.

“As you frame it that way, they begin to have a little bit more compassion for themselves, and self-compassion is something that’s so important for survivors to develop,” Viviani says. In her experience, survivors are hard on themselves, often exercising magical thinking about what they should or should not have been able to do as a child. “As we help them develop self-compassion and self-awareness, we see the guilt begin to dissipate,” she adds.

Regaining a sense of safety

Safety — in emotions, relationships and touches — is a critical component of treatment for a child who has been sexually abused, Holmes stresses.

Counselors should teach clients about safe and unsafe touches, personal boundaries and age-appropriate sexual behavior rules, adds Amanda Jans, a registered mental health counseling intern and mental health therapist for the Child Protection Center in Sarasota. Counselors can also help clients “understand that they are in charge of their bodies, so even if a touch is safe, it doesn’t mean they have to accept it,” she says.

Hula hoops provide a creative way to discuss personal space boundaries with clients, Holmes notes. Counselors can use hula hoops of different sizes to illustrate safe and unsafe boundaries with a parent, sibling, friend or stranger, she explains.

VanDuser helps clients engage in safety planning by having them draw their hand on a piece of paper. For each finger, they figure out a corresponding person they can tell if something happens to them in the future.

Counselors can also take steps to ensure that their offices are safe settings. Jans, an ACA member who presented on the treatment of child sexual abuse at the ACA 2018 Conference, uses noise machines to ensure privacy and aromatherapy machines to make the environment more comfortable. She also has a collection of kid-friendly materials, so if a child starts to feel dysregulated during a session, he or she can take a break and play basketball or color.

Likewise, if clients are hesitant to discuss the topic, Jans allows them to take a step back. For instance, she has clients read someone else’s experience (either real or fictional) rather than having them write their own story, or she has clients role-play with someone else serving as the main character, not themselves. This distance helps clients move to a place where they eventually can discuss their own stories, she says.

Another technique Jans uses to ease clients into writing and processing their own stories is a word web. Together, Jans and a client will brainstorm words related to the client’s experience and put the words on a web (a set of circles drawn on a paper in a weblike pattern). Jans finds this exercise helps clients get comfortable talking about the subject and, eventually, these words become part of their narrative.

VanDuser also suggests getting out of the office. Sometimes she takes child and adolescent clients to a store to get a candy bar. On the way, she will ask them what they are feeling or noticing. If clients say that someone walking by makes them feel strange, VanDuser asks how they would address this feeling or what they would do if someone approached them. Then they will talk through strategies that would make the client feel safe in this situation.

Taking back control

Survivors of child sexual abuse often feel they can’t control what happens around them or to them, Frazier says. So, counselors can get creative using interventions that return control to these survivors and make them feel safe.

Viviani helps clients regain some sense of control in their lives by teaching grounding and coping skills. “Coping skills are so important to helping them begin to trust in themselves again so that they have the skills to really uncover and deal with the abuse,” she explains.

In sessions, counselors can help clients recognize what their bodies feel when they are triggered. Then they can help clients learn to deescalate through grounding skills such as noticing and naming things in their current surroundings or reminding themselves of where they are and the current date, Viviani says. Rather than reliving the incident — being back in their bedroom at age 5, for example — clients learn to ground themselves in the here and now: “This is Jan. 10, 2019, and I’m sitting in my office.”

VanDuser highly recommends trauma-focused cognitive behavior therapy (TF-CBT) for work with survivors of child sexual abuse. TF-CBT is a short-term treatment, typically 12-16 sessions, that incorporates psychoeducation on traumatic stress for both the child and nonoffending parent or caregiver, skills for identifying and regulating emotions, cognitive behavior therapy and a trauma narrative technique.

For a creative approach, VanDuser suggests letting children use crayons and a lunch bag to create a “garbage bag.” She first writes down all the bad feelings (e.g., fear, anger, shame) the client has about the abuse. As the child finishes working on one of the bad feelings, he or she puts the feeling in the garbage bag. When all the feelings are in the bag, VanDuser lets the client dispose of it however he or she wishes — by burning it, burying it, throwing it in the actual garbage or some other method.

Jans and Holmes suggest empowering clients by giving them some control in session. For example, if clients are feeling sad, the counselor can remind them of the coping strategies they have been working on (perhaps progressive muscle relaxation and grounding techniques) and ask which one they want to use to address this feeling. The counselor could also list the goals of therapy for that day and ask clients which one they want to work on first, Holmes says.

Holmes acknowledges that clients may never make sense of the abuse they suffered, but counselors can help them make sense of the abuse’s impact and aftermath. For Holmes, this meaning making involves clients being empowered to reclaim their lives after abuse rather than being held hostage by it, realizing that trauma doesn’t have to define them and learning to be compassionate with themselves.

The hero who told

Holmes encourages counselors not to shy away from discussing child sexual abuse. “If clinicians hesitate, clients will hesitate. If the clinician avoids it, the client will avoid it,” Holmes says. “It’s the clinician’s responsibility to take the lead on this topic. Sexual abuse is so widespread in our society that we do our clients a disservice when we don’t incorporate sexual abuse histories into our [client] assessments.”

Typically, however, counselors are not the first person a child will tell about the abuse. Often, children first disclose the abuse to a teacher or other school personnel, and their reaction is crucial in ensuring that the child gets help, Viviani says.

Thus, she advises counselors to partner with schools and child advocacy organizations to educate them on what they should do if a child discloses sexual abuse. “They need to know what to do,” Viviani emphasizes. “They need to know what to say to support that child because we may not get another chance, at least until they hit college age when they’re not under that roof anymore, or we may never get that chance again.”

Counselors must also empower survivors of child sexual abuse. “They shouldn’t be waiting for the therapist … or their best friend to ride in and save them. We want them to be the hero of their own story,” Holmes says. “And how we do that is through finding ways they can start to recognize and make safe and healthy decisions about different pieces of their life, and we want to model that even within the therapy environment.”

The end result of TF-CBT is the child writing his or her own narrative of the sexual abuse. VanDuser emphasizes that no matter how the child’s sexual abuse story begins, it always has the same ending: the hero — the child — who told.

 

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Lindsey Phillips is a contributing writer to Counseling Today and a UX content strategist living in Northern Virginia. Contact her at consulting@lindseynphillips.com or through her website at lindseynphillips.com.

Letters to the editorct@counseling.org

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

The wise support system in domestic violence rescue efforts

By David L. Prucha April 9, 2018

A lot has been written about domestic violence, the cycles that keep people in violent relationships and how to get out of them. The commentary focuses on the role of substance abuse, the role of personality disorders and a cycle of conflict that ends with the exchange of a “never again” promise. Wash, rinse, repeat.

Although I believe these are relevant factors in violent relationships, a dynamic often emerges between the victim and her concerned loved ones, and this dynamic might play a role in keeping the violent relationship intact. It is of course sensible to think about the relationship between the abuser and the victim, but what else can we learn by looking at the relationship between the victim and her potential safety net?

If you are a family member looking from the outside in on a violent relationship, things look pretty black and white. The abuser is a bad guy. In fact, it’s probably better to use the word “evil.” He is taking advantage of someone smaller than him, he’s probably done this in previous relationships, and his promise to change can’t be trusted. He is one-dimensional: bad. The hottest place in hell is reserved for men of his ilk.

For those on the outside looking in, this is terrifying. Their loved one is in danger, she is captive, and if that wasn’t bad enough, she seems ambivalent about her chains. This leads family and friends to express their hatred for the abuser, but in their desperation, they might also express their frustration with the victim: “You’re smarter than this. I can’t believe you got yourself into this.” For those in the victim’s support system, a life might be hanging in the balance, so this seems no time to mince words.

If you are on the inside of the relationship looking outward, however, the picture can appear very different. Although the victim can certainly recognize her partner’s shortcomings, she cannot quite see what her support system sees. She doesn’t see a one-dimensional evil man.

Instead, she sees someone who is conflicted, someone who hates himself, someone who can’t get a grip on his emotions. Because she knows the “inner him,” she struggles to reconcile the blunt feedback from her family with the person she loves. The two pictures just don’t add up.

Could her partner really be as manipulative and cold as they say? Surely not. His regret and anguish are sincere. She has witnessed him cry out of self-hatred, and evil men don’t do that. He is broken but not bad. He wants to change, and she can’t imagine leaving because she doesn’t want to be like everyone else who has left him in the past.

 

A disciplined rescue

Before people are open to receiving help, they have to trust that the complexity of their problem is well-understood. When families characterize their loved one’s abuser as pure evil, a demonic caricature with cloven hoof, it delegitimizes their feedback, because for the victim, this evil cartoon character is nowhere to be found. In fact, the blunt feedback often has the opposite effect — it reinforces for the victim that the goodness of her partner isn’t being taken into account. This hardens her conviction that she is alone in understanding the situation, and this has the unintended consequence of further isolating her.

Given that explanation, what can be done? One way to intervene is to help the victim understand that there is a difference between evil people and destructive people, but both types of people can do the same amount of damage. In making this distinction, it validates that her partner is not a one-dimensional monster without dismissing the fact that a destructive reality still exists that needs to be addressed. This approach doesn’t isolate the victim from her support system. It also helps her understand why her situation feels so gut-wrenching: She has to leave someone who is partly good.

But partly good is not good enough. When we offer the truth that people are never entirely good or entirely evil, we offer an alternative worldview that enables victims to refine their partner-selection process in the future.

No longer should they reassure themselves if a destructive person shows goodness, because displays of goodness are no longer sufficient criteria for choosing a partner. Instead, the criteria become more nuanced. Despite the display of goodness, is this person also destructive? Victims learn that the presence of goodness and vulnerability are not the only variables to consider.

A second way to help is to teach victims that empathy is a morally neutral disposition: It can lead to both health and destruction. After all, the best predators use empathy to scan for the psychological vulnerabilities of other people. This maximizes predators’ ability to exploit.

In the cases of victims of domestic violence, their empathy is doing them harm. They are spending too much time thinking about how leaving the relationship would impact their partner and not enough time thinking about how they are themselves being harmed. Their high capacity for empathy has led them to walk around in the mind of their abuser for far too long, thinking his thoughts and feeling his feelings. The victim is not in her situation because she is foolish but because she has not learned how to manage her empathic impulses. Learning how to power down her empathy is vital, and she can do this by learning how to reprioritize her own needs.

Reprioritizing her needs can lead to feelings of guilt, and this comes from a sense that she is being selfish. The victim is in the habit of giving 100 apples to her partner without taking one for herself, so now taking 50 apples feels incredibly wrong. However, with the right help, she can learn that meeting her own needs is not selfish but is instead necessary to be truly generous.

In fact, when we compulsively engage with something that damages our well-being, it is not generosity — it is addiction. The person with alcoholism no longer enjoys the drink, and the person addicted to empathy no longer enjoys giving. Instead, they both feel bound to their habits. It’s not that virtue motivates the victim to give away the 100 apples; it’s that she doesn’t know how to give less than 100 apples away.

When victims learn that empathy has become a force for harm in their lives and that true generosity can’t flow forth from inner compulsion, the sense of virtue that they previously associated with staying in the relationship is tarnished. It isn’t that the abuser is without a gradient of goodness; it’s that he is still profoundly dangerous. It’s not that she is motivated by virtue; it’s that her empathy has kept her from seeing that her needs for safety and love should be more important to her than his need to avoid anxiety or sadness.

The hope is that thinking about how support systems can unintentionally create defensiveness and isolation in victims of domestic violence will lead to better rescue strategies. Although it feels repugnant for support systems to acknowledge the goodness in the victimizer, in some cases this might allow the victim to see more clearly the destructiveness of her partner. If members of the support system are able to stop themselves from accusing the perpetrator of simply being evil, this might lead the victim to feel powerfully understood. Perhaps the intimacy of feeling understood will increase the victim’s trust in the bridge away from her relationship and into the arms of those who love her.

 

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David L. Prucha is an adjunct professor of psychology at Johnson and Wales University in Denver, Colorado. He is also a licensed professional counselor who maintains an independent practice that specializes in depressive disorders, anxiety disorders, and trauma and stressor-related disorders. Email him at contact@pruchacounseling.com.

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

The toll of childhood trauma

By Laurie Meyers June 23, 2014

Little-girl_brandingMention the word trauma to Americans in the 21st century, and their thoughts are likely to turn to images of terrorism, war, natural disasters and a seemingly continual stream of school shootings. The horrific scenes at Newtown and Columbine still dominate public consciousness, particularly when our society discusses child trauma. While those events make headlines, however, counseling professionals say the most pervasive traumatic threat to children is found not in big events or stranger danger, but in chronic and systemic violence that happens in or close to the home.

This kind of ongoing trauma, much of which takes place out of public view, leaves deep scars that can cause a lifetime of emotional, mental, physical and social dysfunction if left untreated. Research shows that chronic, complex trauma can even rewire a child’s brain, leading to cognitive and developmental issues.

The good news is that counselors in all areas of practice — in schools, agencies, shelters, clinics, private practice and elsewhere — can and are working with children and, when possible, their parents to stop the cycle of violence, or at least to mitigate its effects.

Behind closed doors

The number of children exposed to violence in the United States is staggering. According to the National Survey of Children’s Exposure to Violence (NatSCEV), funded by the U.S. Department of Justice and the Centers for Disease Control and Prevention (CDC) and carried out by the University of New Hampshire’s Crimes against Children Research Center, more than 60 percent of children surveyed had been exposed to direct or indirect violence during the 12 months prior to the survey. Nearly half — 46.3 percent — had been assaulted at least once in the past year, meaning they had experienced one or more of the following: any physical assault, assault with a weapon, assault with injury, attempted assault, attempted or completed kidnapping, assault by a brother or sister, assault by another child or adolescent, nonsexual genital assault, dating violence, bias attacks or threats. One in 10 had experienced some form of maltreatment, which includes nonsexual physical abuse, psychological or emotional abuse, child neglect and custodial interference. Other CDC research indicates that 1 in 4 girls and 1 in 6 boys are victims of sexual abuse. However, many experts emphasize that due to the stigma involved, sexual abuse is underreported.

Significant exposure to violence and trauma can also lead to illness later in life. From 1995-1997, the CDC, in collaboration with Kaiser Permanente, collected detailed medical information from 17,000 patients at Kaiser’s Health Appraisal Clinic in San Diego. These patients also answered detailed questions about childhood experiences of abuse, neglect and family dysfunction. The initial study, Adverse Childhood Experiences, as well as more than 50 studies since using the same population, found that adult survivors of childhood abuse are more likely to develop chronic conditions and diseases such as heart disease, obesity, cancer, chronic obstructive pulmonary disease and liver disease. They are also more likely to engage in risky health behaviors such as smoking and drug and alcohol abuse. In addition, adult survivors of child abuse may have autobiographical memory problems; exhibit increased problems with depression, anxiety and other mental illnesses; and struggle with suicidal tendencies.

NatSCEV data, collected between January and May 2008, indicate that one in 10 children surveyed experienced five or more incidents of direct violence. It is this kind of ongoing abuse that can cause polyvictimization, or what many researchers call complex trauma — repeated exposure to traumatic events over time and often at the hands of caregivers or other loved ones.

“This cumulative trauma has much more serious effects than a single event,” says David Lawson, a licensed professional counselor (LPC) and licensed marriage and family therapist in Nacogdoches, Texas, who has worked with victims and perpetrators of sexual and domestic abuse since the 1980s. Because the abuse is ongoing, it disrupts a child’s sense of security, safety and self and alters the way he or she sees others, explains Lawson, an American Counseling Association member who is also a researcher and professor in the school psychology and counseling program at Stephen F. Austin State University in Nacogdoches.

“In childhood, attachments are still forming, and abuse can shatter this developing ability,” says Jennifer Baggerly, an ACA member, LPC and play therapist who studies child trauma intervention. “It can also distort their forming personality and the way they interact with people as a whole.” This distortion can cause the child to believe that the world is an unsafe place and that people aren’t trustworthy, adds Baggerly, an associate professor and chair of the Department of Counseling and Human Services at the University of North Texas at Dallas.

That pattern of uncertainty and instability can cause cognitive distortion, dissociation and problems with emotional self-regulation and relationship formation, and even alter a child’s brain structure, notes Lawson, the author of Family Violence: Explanations and Evidence-Based Clinical Practice, published by ACA in 2013.

“Children get stuck in flight or fight,” adds Baggerly. “Everything is a threat, so instead of strengthening the prefrontal cortex, the brain operates more from the limbic system, which causes them to be more hypervigilant.”

Because they are almost constantly on alert, these children and adolescents most of the time use what Lawson calls their “survival brain” instead of their “learning brain.” Childhood and adolescence are periods in which the brain is developing rapidly and crucial cognitive skills are being learned. If children and adolescents spend too much time in survival mode, they are not accessing areas in the brain that are responsible for learning developmentally appropriate cognitive skills and laying down the neural pathways that are critical to future learning.

“As the child gets older, this chronic hypervigilance — and the overload of cortisol that comes with it — completely remaps the brain and just stifles development,” says Gail Roaten, president-elect of the Association for Child and Adolescent Counseling, a division of ACA. “You see them lose ground cognitively, especially in their ability to learn.”

Support and stability

Traumatized children’s problems with cognition, learning, self-regulation and development can last a lifetime, making it more likely that they will continue the cycle of abuse in their relationships, abuse drugs and alcohol, have trouble finding and keeping jobs or end up in the criminal justice system. Adults who were traumatized as children also are much more likely to face a host of physical and mental health problems.

The situation is far from hopeless, however. Counseling interventions for trauma can make a dramatic difference, and the earlier a child starts receiving therapy, the better. A variety of techniques have proved to be effective, but interventions are most successful when a supportive environment is created, Lawson emphasizes. Whenever possible, a parent or parents should be participants in a child’s therapy (as long as they are not the perpetrators of the abuse), and if not the biological parents, then foster parents or grandparents.

“I try to bring in whoever can help build a support system for the child,” Lawson says, “because an hour a week [of counseling] is woefully inadequate, and I need to have them able to take what they learn in therapy into the home.”

In many cases, parents or caregivers need help learning how to support the abused child emotionally, he says. When parents come to sessions with their children, the counselor can help the parents learn not just the best way to support the child in therapy, but also how to strengthen their parenting skills.

“We really emphasize connection,” Lawson says. “Once they [abused children] have attachment, they may be ready to tell parents about their abuse and may just blurt it out at home. I try to prepare parents to listen to the child. If the parents are not comfortable addressing this [topic], I have them at least write down what the child says and then use that as a therapeutic prompt.”

In sessions, Lawson guides parents, teaching them how to interact and better bond with children who have been traumatized. Some parents and caregivers have never really learned how to play with their children, he says.

At the same time, he notes that learning positive interaction skills is not just about the fun stuff. Parents and caregivers also need to know how to effectively discipline the child. “Many times when parents find out that their child has been abused, they are hesitant to discipline or correct behavior because they feel sorry for them,” he says. “Or they come down too hard.”

Lawson encourages parents to use time-outs, to not respond when a child is acting out with attention-getting behavior and to not use corporal punishment.

In the absence of parents or other supportive adults, the counselor may become the stabilizing adult in a traumatized child’s life. Although the counselor is not with the child as often as a parent or caregiver would be, just having someone who is concerned and will listen to whatever the child wants to say can be enough for an abused child to start to heal, Lawson says, even if he or she never chooses to talk about the abuse. He notes that even in the absence of other supportive figures, the therapeutic bond between counselor and child can help in decreasing hyperarousal.

Counselors need to know that although it may seem best to address the child’s trauma right away, establishing and cementing the therapeutic relationship must come first, Lawson says. The child needs to feel safe and supported — even if it is only in the counselor’s office — before he or she can begin to process the trauma.

“You’re trying to get them in a safe place if possible, or at least a predictable place,” Lawson says. “Then we can start teaching them how to cope [with the trauma] without lashing out or
avoiding it.”

Abused children do not know how to cope with what they are experiencing, Lawson says. It is common for children who are traumatized to lash out in anger when stressed and to feel that the best way to establish some sort of stability in their lives is to try to control everything. They may be moody, irritable or withdrawn. Abused children may also bully and hit other children or turn their anger on themselves and engage in self-abusive behaviors such as cutting.

Once a child feels supported, the counselor can also begin to teach the child how to self-soothe. Lawson guides traumatized children in using calming techniques such as diaphragmatic breathing or grounding themselves by focusing on something external such as the ticking of the clock or the texture of their clothes. “The point is to experience emotions in a safe place and cut out bad coping behaviors,” he says.

Safety first

Jennifer Foster, an assistant professor in the Department of Counselor Education and Counseling Psychology at Western Michigan University, studies child sexual abuse. Much of her research has involved listening to the narratives of abuse victims and how they perceive what has happened to them. Although these children display myriad reactions and emotions, Foster says two themes are always prominent: fear and safety.

“Child victims of sexual abuse often view the world as unsafe and are likely to enter counseling with unresolved fears,” Foster says. “They need help from their counselor to learn how to cope with their fears.”

“Although adults often see disclosure as a positive thing that will put an end to the abuse, for many children it is embarrassing and frightening, especially for those who feel at fault for their abuse and believe they will be blamed or, worse, not believed,” says Foster, who studied the experiences of sexually abused children for her dissertation.

Several counseling interventions are designed to help sexually abused children regain a sense of safety. One is called the “safe place technique,” in which a counselor guides the child in visualizing and vividly describing an imaginary safe place.

“The counselor may say, ‘Close your eyes and picture a special place where you feel completely safe,’” Foster explains. “This can be followed by specific questions to capture additional details such as: What do you see? What do you hear? What do you feel? What are you doing in your safe place? The details are recorded by the counselor and used to create a script.”

Once the safe place has been established, the child can return to it mentally anytime he or she feels stressed or scared, Foster says.

Another intervention called the “comfort kit,” developed by Liana Lowenstein, helps children who engage in nonsuicidal self-injury to learn self-soothing strategies, says Foster. “Counselors help children brainstorm and create a list of items that bring them comfort and make them feel better,” she explains. “Although the process is guided by the counselor, children are the ones who choose what will go inside their box or bag.”

Foster says children commonly include items such as a blanket, music, a favorite stuffed animal, written or recorded guided imagery, a stress ball, a list of relaxation activities, bubbles (for deep breathing exercises), a favorite book, a picture of a caring person or special place, a journal and pen, art supplies and a list of self-affirmations.

Foster is also a proponent of bibliotherapy. “Children’s books about sexual abuse can introduce child victims to others who have had similar experiences, which may lead to decreased feelings of isolation and normalize their trauma-related symptoms,” she says.

Books can also provide comfort, offer coping suggestions and teach kids important lessons such as that the abuse is not their fault, Foster adds.

Because fear is a predominant issue for child victims of sexual abuse, Foster also recommends stories that specifically address feeling afraid. Her suggestions include Once Upon a Time: Therapeutic Stories That Teach and Heal by Nancy Davis and A Terrible Thing Happened: A Story for Children Who Have Witnessed Violence or Trauma by Margaret Holmes. To help older adolescents explore their memories and feelings connected to sexual abuse, Foster recommends The Secret: Art & Healing from Sexual Abuse by Francie Lyshak-Stelzer. Foster notes that the author’s artwork is particularly effective at capturing fear and the myriad other feelings generated by abuse.

Finding relief through play

Play therapy is one of the most commonly used interventions with children, particularly those who have suffered complex trauma, meaning they have experienced long-term (and often multiple types of) abuse, says Roaten, an LPC who works with traumatized children in clinics and schools, and an associate professor at Hardin-Simmons University in Abilene, Texas.

Most therapeutic playrooms feature a fairly specific set of toys that might include an art center, play dough, a Bobo doll (an inflatable plastic doll modeled after the inflatable clown used in Alfred Bandura’s seminal study on children and aggression), a dollhouse with miniature people, animal figures, toy weapons, costumes and a sandbox. These toys and activities help children to act out their experiences in a safe and less negative manner, Roaten says. For instance, she recounts treating one child who “would just attack and slash the doll where the penis was. She was a victim of sexual abuse.”

In some cases, Roaten says, children just “play through,” processing their trauma entirely through play without needing to talk to the play therapist.

In many instances, Baggerly says, traumatized children act out things they aren’t able to verbalize. She once treated a 6-year-old who didn’t speak for about 10 sessions because the girl had a severe case of internalized anxiety and depression. But as the girl played, she would express her rage by taking a gun and shooting the Bobo doll in the head, stomach and groin area. Baggerly took this cue as a chance to ask the child about the anger and hurt she was feeling.

Catherine Tucker, a licensed mental health counselor who works with traumatized children in her role as a counselor supervisor and consultant, uses a child and family therapy called Theraplay, which was developed by the Theraplay Institute in the 1960s. “Theraplay works on a four-dimensional model: structure, nurture, engagement and challenge,” says Tucker, an associate professor in the college of education at Indiana State University.

Theraplay builds and enhances attachment, self-esteem, trust in others and engagement through participation in simple games. The idea is that the four dimensions — structure, nurture, engagement and challenge — are needed by children for healthy emotional and psychological development. The “play” in Theraplay is built around activities that teach participants what the elements of those dimensions are. Ideally, children engage in Theraplay with their parents or caregivers. Participating together teaches skills to parents or caregivers who don’t know how to provide the four dimensions, while enhancing the bond with the child. In the absence of parents or caregivers — whether because they are abusive or because they cannot or do not want to participate — the counselor plays directly with the child so the child can still learn how to interact in an emotionally healthy way.

The games and activities are simple — suitable for children as young as 1, yet still engaging for older children — and include things such as blowing bubbles, playing with stuffed animals, cotton ball hockey, cotton ball wars and newspaper basketball. The activities teach parenting skills and also help traumatized children with affect regulation, impulse control, feeling safe and not feeling like they have to be in control of the world, Tucker says. She notes that, oftentimes, kids who have suffered trauma feel like they have to be in charge either because a parent is abusive or simply doesn’t know how to provide a sense of security or stability, or because the child’s sense of control is being undermined by the abuse he or she experienced at the hands of another adult or peer.

Finding help at school

Counselors who are treating traumatized children should tap all available resources to help these clients, Lawson says, working not only with caregivers or other relatives but also with the child’s school. School counselors may be a source of additional one-on-one counseling for the child, or they could get the child involved in group activities with other children who are trauma victims or with children who share common interests such as music, sports or art, Lawson says. These peer networks provide abused children additional sources of support and can also teach them how to interact with people — something that many abused and isolated children have never learned to do.

Perpetrators of abuse seek to control and isolate their victims. An abusive parent has the power to cut off or severely limit a child’s healthy interactions with people outside of the circle of abuse. “[These] kids often didn’t learn social skills because they are kept away from other people,” Lawson says.

Abuse is often part of a viciously long-lived cycle, handed down from generation to generation, Lawson adds. Parents who were abused as children often grow up to abuse their own children. Even if parents with an abusive background are not abusive themselves, they may still carry on other dysfunctional behaviors, he says.

“You may have three or four generations of people [who] have a very skewed view of how to interact with people,” he says. “So they never learn how to interact with others. You have to help [these children] connect with other sources.”

School counselors also can play important roles as advocates and educators. Many people — including teachers and administrators — do not understand that many children who act out are doing so because they have been or are being abused, Tucker asserts.

“School counselors can really make a difference by making sure that kids get evaluated instead of just automatically disciplined,” Tucker says.

“So many boys end up in the criminal justice system because they were physically acting out in response to trauma,” she adds.

School counselors can also help abused and traumatized children learn how to help themselves, says Elsa Leggett, an ACA member, associate professor of counseling at the University of Houston-Victoria and president of the Association for Child and Adolescent Counseling.

“Talk to kids about safety plans,” Leggett urges. “Ask them, ‘When abusive things are going on at home, where do you go? How do you know when things are getting dangerous?’”

The most important thing that all practicing counselors can do to address childhood trauma is to ask questions, Lawson says. Children — and sometimes adults who were traumatized as children — don’t always recognize what they’ve experienced as abuse, so rather than asking “have you been abused?” Lawson instructs his students to pose questions such as “has anyone ever hit you?” and “has anyone ever touched you in a way that made you feel uncomfortable?”

ACA member Cynthia Miller is an assistant professor of counseling at South University in Richmond, Virginia, and an LPC who has worked with incarcerated women. She has seen the kind of positive change that can occur when people get the help they need, but she has also witnessed the pattern of incarceration, addiction and institutionalization that can become entrenched in generation after generation.

“If you want to decrease the amount of money we spend on treating people with substance abuse or incarceration,” Miller says, “address child abuse.”

Caring for children during a disaster

Although ongoing trauma causes the biggest and longest-lasting kind of damage, one-time events can also create problems that linger. It is particularly important for children to receive timely counseling intervention, experts say.

“Typically, most children will have short-term responses to a disaster that include five basic realms,” Baggerly says. These realms are:

  • Physical: Symptoms include headache or stomachache
  • Thought process: Children exhibit confusion and inattention
  • Emotional: Children are scared and sad
  • Behavioral: Children might become very withdrawn or clingy, or may start sucking their thumb or wetting the bed again
  • Spiritual/worldview: Children may question their beliefs about God and the world

(For more information about typical trauma responses and recommended interventions, see “Children’s trauma responses and intervention guidelines” below.)

“Typically these [responses] don’t last long,” Baggerly says, “but that depends on the kind of support kids get in the immediate aftermath.”

Ultimately, the purpose of any counseling intervention after a traumatic event is to reduce or eliminate a child’s anxiety and stress, Baggerly asserts. She attempts to do that by “resetting” the child and connecting him or her to coping strategies.

“They need caring family and community support,” Baggerly says, “but if it is a huge disaster, then parents and teachers are equally traumatized, so they are not able to give support to kids. That’s when you need to bring people from outside.”

Some children are at greater risk than others, Baggerly says. “Kids who don’t have supportive family [and] who already have anxiety or have some type of developmental disability often will have ongoing symptoms that go longer than 30 days,” she explains. “Counselors need to triage to find out who is at most risk.”

During her roughly dozen years of experience working with chronic trauma and disasters, Baggerly has developed an integrated approach that she calls disaster response play therapy. The approach uses a trauma-informed philosophy in which counselors train parents and teachers in typical and atypical reactions to disasters so they can screen children and determine which ones need more help, she explains. “We also normalize typical symptoms, provide psychoeducation that informs kids about the impact of disasters, teach them coping strategies and provide them with child-centered play therapy.”

Baggerly usually begins by gathering a group of children and talking with them about rebuilding the community. She also encourages children to use expressive arts or drama to communicate their feelings.

“The other part of what we do is facilitate connection and conversation between kids and parents,” Baggerly says. “We may start out with Theraplay and do structured activities, such as holding hands or singing ‘Row, Row, Row Your Boat.’ The point is to have them [parents and children] looking at each other so that the mirror neurons can be engaged.”

Baggerly also educates parents on activities they can do at home with their children. She refers them to an online workbook, “After the Storm,” which has scales of 1 to 10 or a thermometer that kids can fill in to indicate how much stress they are feeling.

Roaten often does volunteer trauma work and provided on-site support in the wake of the April 2013 fertilizer plant explosion in West, Texas, that killed 15 people, injured more than 150 and caused extensive damage to buildings and property.

“One girl, a seventh-grader, had been standing outside in a neighborhood with a view of the plant and observed the explosion itself,” Roaten says. “So she had that image in her head and it would not go away. I taught her some deep breathing and progressive relaxation and did some guided imagery about her favorite place to be.

“When that picture came up in her mind, she could breathe, relax and go to her good place. By the fourth day I was there, she was no longer seeing the image.”

Roaten uses expressive therapy for children who aren’t very verbal or who don’t have the vocabulary to talk about their feelings. She brings a sand tray with miniatures of fences, people and buildings. She then allows children (and even adults) to set up scenarios or vignettes that help them express and act out what they are feeling.

“I might say something like, ‘Create your world before [Hurricane] Katrina; then create your world after Katrina,” Roaten explains.

Roaten also uses trauma-focused cognitive behavior therapy to help children and adolescents learn coping skills.

“You teach them about trauma and its impact on them,” she explains. “Then you teach them relaxation and breathing skills. Once you get them to be able to self-soothe, relax and be calm, you can help them deal with pictures or scenarios that come up. You help them change the story — what they are telling themselves and what that means — which helps them work through the trauma a little bit at a time.”

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Children’s trauma responses and intervention guidelines

 

Preschool through 2nd grade

Typical trauma responses:

  • Believes death is reversible
  • Magical thinking
  • Intense but brief grief responses
  • Worries others will die
  • Separation anxiety
  • Avoidance
  • Regressive symptoms
  • Fear of the dark
  • Reenactment through traumatic play

Intervention guidelines:

  • Give simple, concrete explanations as needed
  • Provide physical closeness
  • Allow expression through play
  • Read storybooks such as A Terrible Thing Happened, Brave Bart, Don’t Pop Your Cork on Monday

 

3rd through 6th grade

Typical trauma responses:

  • Asks a lot of questions
  • Begins to understand that death is permanent
  • Worries about own death
  • Increased fighting and aggression
  • Hyperactivity and inattentiveness
  • Withdrawal from friends
  • Reenactment though traumatic play

Intervention guidelines:

  • Give clear, accurate explanations
  • Allow expression through art, play or journaling
  • Read storybooks

 

Middle school

Typical trauma responses:

  • Physical symptoms such as headaches and stomachaches
  • Wide range of emotions
  • More verbal but still needs physical outlet
  • Arguments and fighting
  • Moodiness

Intervention guidelines:

  • Be accepting of moodiness
  • Be supportive and discuss when they are ready
  • Groups with structured activities or games

 

High school

Typical trauma responses:

  • Understands death is irreversible but believe it won’t happen to them
  • Depression
  • Risk-taking behaviors
  • Lack of concentration
  • Decline in responsible behavior
  • Apathy
  • Rebellion at home or school

Intervention guidelines:

  • Listen
  • Encourage expression of feelings
  • Groups with guiding questions and projects

 

Source: “Systematic Trauma Interventions for Children: A 10-Step Protocol,” by Jennifer Baggerly in Terrorism, Trauma and Tragedies: A Counselor’s Guide to Preparing and Responding, third edition, American Counseling Association Foundation, 201

 

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ACA Traumatology Interest Network

Counselors and counselors-in-training who have an interest in providing counseling services to trauma- or disaster-affected individuals and communities should consider joining the ACA Traumatology Interest Network. Network participants share insights, experiences, new plans and advances in trauma counseling services. For more information on joining the interest network, go to counseling.org/aca-community/aca-groups/interest-networks.

 

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To contact individuals interviewed for this article, email:

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Laurie Meyers is the senior writer for Counseling Today. Contact her at lmeyers@counseling.org.

Letters to the editor: ct@counseling.org

Working through the hurt

By Bethany Bray March 25, 2014

abusedMore than one-third of U.S. women (35.6 percent) and more than one-quarter of U.S. men (28.5 percent) have experienced rape, physical violence or stalking by an intimate partner during their lifetime, according to a recent survey by the National Center for Injury Prevention and Control.

Those statistics suggest that counselors of all specialties, from school counselors to addictions counselors, are likely to encounter clients who are familiar with the impact of domestic violence. Counselors with expertise in this area stress that the specter of domestic violence is a complicated issue that helping professionals must address with grace and competency.

Working past domestic violence in counseling sessions will almost assuredly involve other issues, says Christine Murray, a domestic violence researcher and associate professor in the University of North Carolina at Greensboro (UNCG) Department of Counseling and Educational Development. Those issues might range from self-esteem, anxiety and relationship challenges to financial problems and finding employment. As one example, Murray says, an abusive spouse may not have allowed your client to hold a job outside of the home or even leave the house unsupervised.

“Domestic violence is something that impacts someone’s mental health, but there are all these other pieces to it,” says Murray, an American Counseling Association member who teaches a class on family violence to her counseling students. “There’s no easy way to say, ‘This type of abuse has this specific answer.’ It’s different with each person. Any form of abuse can be really hurtful to somebody.”

A counselor’s approach might be different with each client involved in domestic violence and should be tailored to his or her experiences and symptoms. Clients may be victims of domestic violence, perpetrators of domestic violence or witnesses — for instance, a child or someone else in the home who saw the abuse occur.

Murray, who prefers the term intimate partner violence to domestic violence, adds a fourth category: survivors. Survivors may be out of their abusive relationship but still experiencing lingering effects of trauma, such as nightmares or flashbacks. According to Murray, counselors are more likely to encounter clients at the “survivor” stage than clients who are still in the thick of an abusive relationship.

Murray, a licensed professional counselor (LPC) and licensed marriage and family therapist, has good reason for applying the term survivor to clients who have withstood abusive relationships. “We don’t want to view people who have been abused as damaged. They may feel that way, but we need to help them and promote that view [that they are not damaged] in society,” she says. “They can have a happy life. They can have happy relationships. There is recovery [and] there is hope that people can experience even after having a horrific experience.”

“Just the fact that they’ve survived and lived to tell the story shows how strong they are, how resourceful,” Murray continues. “There is a lot of strength that comes through that process. They can be encouraged, and they don’t need to be ruined, [even though] that’s often how
they feel.”

Introducing the topic in session

Nancymarie Bride, an LPC, certified clinical mental health counselor and adjunct faculty member at Kean University in New Jersey, says individuals who have experienced domestic violence are often marginalized by the general public and even by mental health professionals. For that reason, these individuals often “do not expect to be believed,” says Bride, an ACA member and past president of the New Jersey Counseling Association who has worked with people affected by domestic violence — both victims and perpetrators — since the 1980s in private practice and group work. “Even sometimes when domestic violence is recognized, it’s not taken seriously enough,” she says.

Counselors shouldn’t expect that clients will bring up their abuse histories on their own, and there are several reasons for that, Murray says. For instance, some clients may not even recognize they are in an abusive, controlling relationship because that type of relationship may be “normal” for them, she says. Other clients assume that the term abuse should be applied only if a spouse or intimate partner has hurt them physically. These clients do not necessarily recognize psychological, verbal or other nonphysical forms of abuse as abuse.

But a lack of recognition is not the only thing that keeps clients from bringing up a history of abuse with counselors, Murray says. Many victims and survivors feel a sense of shame or embarrassment about these experiences. Some even feel they are somehow to blame for being the target of abuse. Others fear being judged or are otherwise unsure of how a counselor might react to their revelation. And some clients try to keep the truth hidden for safety reasons, Murray says, having been threatened with further harm by their perpetrators should they ever tell anyone.

Oftentimes, a client’s history of abuse emerges gradually — and only after the therapeutic alliance between the counselor and client has grown strong, says Allison Crowe, an assistant professor of counseling at East Carolina University who conducts research on domestic violence. “Chances are, [the client] is trying to determine whether or not I’m trustworthy, especially if they’ve been to professionals in the past,” says Crowe, an ACA member who is an LPC and approved clinical supervisor. “Many folks who have gone to seek help have not had a good experience and are very nervous about bringing this up with the next person.”

What if a counselor comes to suspect abuse or intimate partner violence, but the client doesn’t recognize the problem? The way that counselors word their questions is very important, says Brandon Ballantyne, an LPC in Reading, Pa., who facilitates domestic violence evaluations and makes treatment recommendations for families referred to counseling by the county’s department of children and youth services.

He suggests that counselors talk to clients about what it would look like if there were a problem. “You’re not trying to change their mind or indicate there is a problem but [rather] get them to talk about what would signal or indicate there is a problem,” says Ballantyne, a member of ACA. “It helps if it comes from their mouth. You know what direction you want to take the session, but you don’t want to plant any ideas.”

Murray and Bride recommend using the Duluth Model’s Power and Control Wheel (theduluthmodel.org), which categorizes specific abuse behaviors counselors can talk through with clients, including using coercion and threats, using intimidation, using isolation, using economic abuse, using emotional abuse and minimizing, denying and blaming.

Once the counselor establishes what the client views as abuse, the counselor can begin to challenge those beliefs, Ballantyne says. He adds that open-ended questions are most useful. For example, he says, ask the client how his or her personal definition of a healthy relationship is working out. What has it led to? Has it led the person to counseling?

“You never have to feel pressured to convince the client that they should think the way you’re thinking,” he says. “It’s OK to disagree. When you disagree, there’s more opportunity for growth. [Say], ‘It’s OK for us to think differently about this, but let’s talk a little bit more about it.’ Anytime you can [give] the control back to the client, I think that’s when changes tend to stick a little more.”

Self-perception and society’s perception

Clients who have a history with domestic violence can present with myriad related issues, Crowe says. For instance, they may have symptoms of posttraumatic stress disorder (PTSD), including feeling unsafe, experiencing flashbacks or being jumpy, she says. The counselors interviewed for this article also mentioned helping these clients with issues such as anxiety, depression, panic attacks, emotional withdrawal, feelings of helplessness and low self-esteem.

The self-blame and guilt associated with not leaving an abusive relationship sooner, especially if that relationship also involved children, is another major issue that counselors and clients must commonly work through together, Crowe says.

Providing psychoeducation and teaching clients what a healthy relationship looks like are basic but useful techniques that counselors can use, she says. Clients may need to learn that the manipulation and power struggles they have experienced in their intimate relationships — such as a spouse not allowing them to carry a checkbook or go grocery shopping — aren’t normal or healthy, Crowe says. The process involves clients “learning all that abuse entails and forgiving [themselves],” she adds.

Crowe and Murray recently surveyed and interviewed more than 230 domestic violence survivors (male and female) for a research project. The duo is preparing to publish its findings in an educational journal, as well as through a website (seethetriumph.org) and social media campaign.

Through their research, Murray and Crowe heard from domestic violence survivors who felt stigmatized not just in general society but also by the professionals they had turned to for help. In one case, a woman was fired because her employer didn’t want her abusive spouse showing up at the workplace to stalk her. In another case, a police officer asked a victim of domestic violence out on a date when she came to the station to file a report. Another interviewee said her doctor told her she was “stupid” for not leaving an abusive husband.

“The stories that we heard were overwhelming,” Crowe says. “I was taken aback by the poignancy of what these [people] experienced. When someone sees you as ‘she lets her husband beat her,’ people start forming ideas about you. … An incredible takeaway [from the research project] is how much survivors want to help each other” by sharing their stories of survival.

Helping clients recover

Safety first: A counselor working with someone who is experiencing domestic violence must make the client’s safety and well-being of the utmost importance.

Understand that simply giving your business card to an abuse victim can put that person in danger should an overcontrolling spouse or partner see the card and lash out in anger, Bride warns.

Safety should also be a counselor’s first and foremost consideration when choosing interventions to use with a client, says Murray. For example, counselors should use caution when working on assertiveness with a client who is still in a relationship with his or her abuser. If a client were to go home and try being more assertive with his or her partner, that action might spark more abuse, she points out.

Counselors should create and talk through a safety plan with their clients. This intervention can be done with children and adults, victims and perpetrators. For victims of intimate partner abuse, a safety plan might include keeping an extra house key and change of clothes in the car in case their spouse or partner throws them out during an argument. For perpetrators, safety planning might include learning to recognize the need to cool off or “take a time out” during an argument — and understanding that doesn’t mean going to a bar or driving down the highway at 90 mph, Bride says.

Murray recommends the Safety Strategies website (DVsafetyplanning.org), created by the Family Violence Research Group in the UNCG Department of Counseling and Educational Development, as a resource for counselors looking to create safety plans with clients.

Treading gently: A client who has been involved in abuse has been traumatized, and discussions about the abusive situation can trigger PTSD-like symptoms, Murray says. Counselors should talk through the client’s emotions, use trauma-informed care and allow the client to control the pace of therapy.

In addition, counselors must guard against judging these clients or even coming across as judgmental, Murray says. “Make sure as a counselor [that] you’re not restigmatizing your client. You never want them to get the impression that it’s their fault,” she says.

Victims or survivors of intimate partner abuse will talk about that abuse only when they are ready, Bride adds. Because they have navigated within a climate of abuse, they know when it is “safe” for them to talk about that abuse and when it is not, she says.

Assessment: Counselors shouldn’t just ask, ‘Have you ever been abused?’ because clients may have different perceptions of abuse, Murray says. Instead, she recommends asking more behavior-specific questions: Has your partner ever called you names? Who makes the decisions in the relationship? Does your partner check up on you? Have you ever been injured in a fight with your partner?

A holistic approach: Be aware that all aspects of the client’s life — from physical and mental health to parenting, finances and housing — can be affected by abuse. Look at all these areas of the person’s life that have been influenced and talk about what the client’s goals are, Murray says. Help them work toward recreating their life to “build back a sense of self-worth,” she says.

Counselors can also help clients learn coping mechanisms to deal with co-parenting children with an abusive ex-spouse or returning to the dating scene after an abusive relationship.

An interdisciplinary approach: Step out of the “counseling box” to work with other agencies in your community, Murray advises. The individuals interviewed for this article agreed that counselors should become knowledgeable about the domestic violence services in their areas, including abuse hotlines, shelters, school resource officers, women’s clinics, victim advocate organizations, support groups and so on. Also touch base and network with other professionals in your community, such as law enforcement personnel and social workers, who have frequent contact with victims of abuse.

Counselors should also learn the basics regarding how a client would file a police report or restraining order. Counselors — especially child and family counselors — should also know how and when to file a report of child endangerment with their state’s department of child services.

Storytelling and self-care: In talking with abuse survivors for their “See the Triumph” project (seethetriumph.org), Crowe and Murray found that many of these individuals craved the chance to tell their story. Likewise, talking through a client’s story in counseling can help the person to heal and feel validated, Murray says. “Understand that time alone may not determine how salient [a client’s] experience of being abused is,” whether that experience took place one year ago or 20 years ago, she says.

Journaling can be another useful therapy tool, she says, as can trauma-focused approaches such as developing coping resources, dealing with stress, goal-setting, relaxation, self-reflection and self-care. Each of these approaches is about “helping them recreate their own identity on their own terms,” explains Murray.

Social support is another key, especially as it relates to rebuilding relationships with friends or family members who may have been cut off from the client’s life during the period when the abuse was taking place.

Cognitive behavior therapy: Ballantyne recommends talking through these clients’ belief systems, particularly their beliefs about interpersonal issues and relationships. Ask them to describe what they think a healthy relationship looks like. He points out that some clients may have witnessed abuse between their parents and grown up regarding this as “normal,” with aggression or abuse representing the only way to work out problems or resolve issues.

“[Ask], ‘How can we work together to change the way you see relationships?’” Ballantyne says. “You’re encouraging them and planting the seed that they can look at relationships differently. They don’t have to continue the pattern of what they’ve seen [in the past].”

Counselors should also encourage these clients to veer away from thought patterns that are “all or nothing,” he says. Explore the middle ground with them and teach them that they don’t have to operate out of extremes. Ballantyne advises developing strategies to help these clients regulate their feelings, such as learning coping skills that will aid them in calming down and working through their sadness, anger or anxiety in a positive way.

Don’t make assumptions: A common assumption is that it is always the male who is abusing the female in a relationship. “That’s the majority, but … [abuse] happens in all types of situations,” Crowe says. There is added stigma in abusive situations that involve people with disabilities, same-sex couples and members of minority cultures, she adds. When it comes to abuse, it is important that counselors step outside of their typical frame of reference and drop all assumptions, she says.

Factor in trauma: It is unethical and inaccurate to diagnose clients without factoring in their abuse histories, Crowe asserts. Counselors should not label clients as having certain problems without first working through their experiences with abuse, she says.

Treating the family as a whole

In cases of abuse, Ballantyne advocates for treating the family as a whole when possible. He says this allows counselors and other helping professionals to focus on relationship patterns and behaviors and to begin addressing these problem areas more effectively.

Although he says the parents and children should also have individual counseling sessions, he believes that family therapy can be a major source of healing and insight. “[Clients can] learn that they can still be connected and care about mom and dad without following through with some of the negative decisions that the parents made,” he says. “They can be healthy individuals and be different from mom and dad, while still caring about mom and dad.”

Ballantyne begins by assessing the full history of each parent, from legal problems to addiction and mental health histories, to fully understand what they have struggled with and been treated for. “A lot of the time, mom or dad has a history of trauma themselves,” he says. “In a lot of cases, I’m discovering that when they’ve experienced that abuse and never been treated for it [and] never learned healthy ways to find intimacy with others, intimacy has always been something that’s scary and threatening.”

He works to return the couple and, ultimately, the family, to a place of stability. Ballantyne recommends that his clients take classes on parenting, conflict resolution, anger management, communication skills, setting boundaries and recognizing abusive behaviors. “The idea of being able to walk away from each other and cool off, and then come back and talk about what the problem is, is sometimes easier said than done. That can take a lot of practice,” he says.

After working with the entire family, a child that has been in a foster care situation can sometimes return home, Ballantyne says. “Not always,” he says, “but you need to go through the [therapy] process for everyone to figure out what’s in the best interest of the child.”

Working with perpetrators

Working with perpetrators of intimate partner violence can be controversial territory, and it brings its own set of challenges.

“I definitely don’t think this is a population that counselors should really work with unless they understand the dynamics of family violence,” Murray says. Crowe and Murray recommend that counselors who are not trained specifically to work with domestic violence perpetrators refer those clients to a specialized treatment program.

Bride ran a program for male batterers that was the first of its kind in her area of New Jersey. The group contained both self-referred members and court-referred participants. She used a process-oriented model that carried an expectation of change in the group’s participants.

Getting the men to take full responsibility for the abuse they had inflicted was paramount. “Getting him to admit his behavior, how bad it was and how hurtful it was, that’s where we had to move him,” Bride says.

Each week, the group leaders, who were specially trained counselors, would ask each participant why he was there. At first, Bride says, the answer was often, “The judge sent me.” Eventually, however, the group leaders weren’t the only ones saying that answer wasn’t sufficient; fellow group members wouldn’t stand for it either. “That was the cohesion, the power of the group,” Bride says.

Even so, she says it took six months — the full length of the program — before some participants could acknowledge the worst of their behavior. “Behavior was the first thing that would change. It takes a lot longer to change attitudes,” she says. “Our hope was that we could actually move the men to a place of empathy. And some of them made it.”

Another technique Bride used was to have group members write letters to the person they had abused, acknowledging their behavior and that it was hurtful. The letters were never sent but rather read aloud in group as an exercise, with members giving each other input.

Safety planning and self-care are also important to work on with perpetrators of abuse, Bride says. They need to learn the warning signs of anger and how to cool down, deal with their anger effectively and have a healthy conversation with their spouse, she says.

In her batterers group, Bride had members work to figure out what triggered their anger so they could learn to control it better. Group leaders had members talk about one of the more recent times their anger had gotten out of control. The group would then “hit the rewind button,” Bride says, and talk through the incident to figure out when and why the perpetrator had gotten so angry.

“How do you know you’re angry? Do you only know when you’re screaming? The minute you know that the discussion has escalated, you have to take a time-out and walk away,” Bride counseled her group members. Part of each group member’s safety plan involved a protocol for taking a time-out, such as ducking into the garage to tinker or going to the gym for a workout.

Being able to talk through what stresses them and then work through those stresses are essential skills for men who are prone to violence, Bride says. “It’s very easy to get men to talk the talk, but you have to get underneath to the pain … and move past being the blamer,” she says. “A lot of men talk about how they stuff [internalize] their anger until it’s an explosion.”

Do no harm

Exposure to domestic violence is more prevalent among their clients than many counselors realize, and Murray says many counselors are ill-equipped and undertrained to deal with the issue properly. “Personally, I would like to see a lot more training on this topic within the profession,” says Murray.

Crowe encourages counselors to look for workshops on domestic or family violence to continue their professional development, especially if they didn’t take a class on the topic in their master’s programs.

Counselors who are undertrained may not know how to talk about abuse with a client or may fail to recognize it altogether, which can be very dangerous, Murray says.

“You can do a lot of damage if you don’t understand [domestic violence],” she says, “and you can do a lot of good if you do.”

 

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Myths of abuse

Counselors need to advocate for victims and survivors of domestic violence and expose some of the myths that are prevalent in society at large, says Nancymarie Bride, a New Jersey-based licensed professional counselor and certified clinical mental health counselor who specializes in working in domestic violence.

 

Myth: Domestic abuse is caused by alcohol or drug abuse or addiction, and going through Alcoholics Anonymous or another rehabilitation program will fix the problem.

Reality: Domestic abuse is an issue separate from addiction. In some cases, domestic abuse may even increase when the perpetrator gets sober, Bride says.

 

Myth: Psychopathology, or mental illness, is to blame for domestic violence. The abuser is “not in his right mind,” under extreme stress or mentally ill.

Reality: This is not always the case, Bride says. “When you look at the pattern of domestic violence, [the perpetrator] believes he has the right to control his partner,” she says.

 

Myth: Battering and abuse do not occur in upper-middle-class families.

Reality: “That’s simply not true,” Bride says. Abuse occurs across all demographics.

 

Myth: The abuse was provoked or the victim “brought it upon herself.”

Reality: A victim does not enjoy the abuse and would not provoke it, Bride says.

 

Myth: Abuse is temporary, occurring only during an abuser’s lapse of control.

Reality: In fact, batterers are often very deliberate, Bride says, carefully inflicting physical or mental wounds on their victims in ways that won’t be seen or noticed by others. “The abuser often has an unbelievable ability to choose the time and place of his attack,” Bride says. “It’s sometimes planned.”

 

Myth: The victim is staying in an abusive relationship because she or he wants to. The person could leave at any time if she or he chose to.

Reality: Leaving an abusive relationship is the most dangerous time for the victim, Bride says. It is important for counselors to understand that victims of domestic violence will leave only when they feel it is safe to do so.

 

Myth: What happens behind closed doors is private. Society shouldn’t interfere with family dynamics and problems.

Reality: This myth only makes it harder for victims to realize they are not responsible for what is happening. Bride draws the following parallel: There is no difference between getting angry and shoving someone you just got in a fender bender with and doing the same thing to your spouse at home. Both are assault, Bride says.

 

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See the Triumph

Learn more about Christine Murray and Allison Crowe’s “See the Triumph” research project and social media campaign created to address intimate partner violence in a related article posted on CT Online: wp.me/p2BxKN-3qo

 

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Bethany Bray is a staff writer for Counseling Today. She can be reached at bbray@counseling.org

Letters to the editor: CT@counseling.org

Triumph tales: Counselors’ domestic violence research project blossoms into website, social media campaign highlighting survivors’ personal stories

By Bethany Bray March 20, 2014

seethetriumphWhile surveying survivors of domestic violence for a recent research project, Allison Crowe and Christine Murray were thoroughly compelled by the stories they heard. So much so that they knew the stories should be shared with a wider audience rather than limited to publication in an academic journal.

In one case, an interviewee said she was fired because her employer didn’t want her abusive spouse showing up at the workplace to stalk her. In another case, a police officer asked a victim of domestic violence out on a date when she came to the station to file a report. Another participant said her doctor told her she was “stupid” for not leaving an abusive husband.

Crowe and Murray, counselor educators and American Counseling Association members who focus on domestic violence and family counseling, launched the “See the Triumph” campaign in January 2013.

While they still plan to publish their research — their article is currently undergoing peer review at a journal – the duo is putting much of their effort into managing a website and social media campaign to share their research findings and spread awareness of the complicated issues and stigma that surround domestic violence.

The project title, “See the Triumph,” is part of a quote from one of their interviewees, who spoke of the triumph of surviving abuse and starting life over.

“The stories that we heard were overwhelming,” says Crowe, an assistant professor of counseling at East Carolina University, a licensed professional counselor and an approved clinical supervisor. “I was taken aback by the poignancy of what these [people] experienced. When someone sees you as ‘she lets her husband beat her,’ people start forming ideas about you.”

Crowe and Murray surveyed more than 230 men and women for their research.

They believe the website and social media campaign offer more timely and immediate ways of sharing their data, while also allowing them to reach a wider population than those who read professional or academic journals.

“We had the data and felt like we needed to do more with it,” Crowe says. “We decided to spread the results in an innovative, nontraditional way. … We wanted to reach more people.”

Seethetriumph.org hosts a blog written by Crowe, Murray and guest bloggers. It also contains a plethora of information and links to resources about domestic violence, such as a “checklist” of questions domestic violence survivors can ask their potential counselors to see if they are properly trained to deal with such a complicated and nuanced issue.

Through their research, the duo has found that domestic violence survivors want –- sometimes even crave the chance — to “share their stories,” says Murray, an associate professor in the University of North Carolina at Greensboro (UNCG) Department of Counseling and Educational Development.

Participants felt validated by talking about what they had been through, says Murray, a licensed professional counselor and licensed marriage and family therapist.

Additionally, some interviewees felt sharing what they had been through and overcome could help others who were still experiencing domestic violence, says Crowe.

“An incredible takeaway is how [survivors] want to help each other,” she says. “Their enthusiasm and passion for helping each other [and] doing what they can was really mind-blowing.”

Crowe and Murray continue to accept survivor narratives through a survey at seethetriumph.org. They are also launching another round of research focusing on immigrants’ perceptions of domestic violence, stigma and culture. A survey for first- and second-generation immigrants is posted on the See the Triumph home page.

Crowe and Murray’s research project began as an exploration of the term “stigma” and its connection to domestic violence.

“There’s a lot more than just blame in the term ‘stigma’,” Crowe explains. “[It involves] blame, discrimination, labeling, secrecy, shame, social exclusion, stereotyping and losing status or power.”

The duo conducted face-to-face interviews with domestic violence survivors about the stigma they experienced in general society as well as at the hands of professional helpers such as police officers, lawyers, medical personnel, mental health workers and others. Crowe and Murray spoke with 12 women, conducting hourlong interviews with each.

The interviews were poignant, says Crowe, and confirmed that many domestic violence survivors do experience stigma, such as the woman who was asked out on a date by the police officer she turned to for help.

Crowe and Murray then expanded their research, surveying more than 200 men and women in the United States and internationally who had experienced domestic violence. For this second round of research, they conducted an online survey with open-ended questions about stigma.

In case after case, interviewees talked of experiencing stigma, from the assumptions people made, such as the belief that abuse victims somehow invite or bring the abuse upon themselves, to a religious leader who told a victim it was her responsibility to keep her marriage to an abusive spouse together at all costs.

“Our results confirmed what we felt in the first round,” Crowe says. “Those results were unfortunate, but very important to us.”

The duo launched Seethetriumph.org and their social media campaign last year after receiving approval from their universities’ research boards.

“One really surprising and rewarding part of this has been the ability to be a part of someone’s healing,” says Crowe. “[The fact] that they can use this as a vehicle for healing is incredible. I think the role of advocate has really been brought out in me and Christine.”

 

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On the web: seethetriumph.org

 

Sample blog posts:

 

“Finding a counselor who is competent to serve survivors”

bit.ly/1gtBlsL

 

“Five things I wish I had known when I left”

bit.ly/1nU6oUp

 

“Being a victim, being a survivor and triumphing: The words that describe our experiences”

bit.ly/1fzP7y3

 

“Intimate partner violence affects everybody, even you”

bit.ly/1dViTfm

 

 

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See the April issue of Counseling Today for an in-depth feature article on counseling victims, survivors and perpetrators of domestic violence, to which Crowe and Murray contributed.

 

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Bethany Bray is a staff writer for Counseling Today. Contact her at bbray@counseling.org

 

Follow Counseling Today on Twitter @ACA_CTonline