Tag Archives: abuse

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

 

Working with sexually abused children

Gregory K. Moffatt November 25, 2013

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

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

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

Stages of therapy with abused children 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Conclusion

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

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

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

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

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

Letters to the editor: ct@counseling.org

 

 

 

Complications when working with sexually abused children

Gregory K. Moffatt November 21, 2013

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

Confidentiality and mandated reporting

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

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

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

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

Hidden agendas

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

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

Assessment versus therapy

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

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

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

Evidence-based therapy

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

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

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

Preparing for court

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

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

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

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

Staying healthy when working with sexually abused children

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

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

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

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

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

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