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Home > The Role of Mental Health Professionals in the Prevention and Treatment of Child Abuse and Neglect > The Role of Mental Health Professionals in the Prevention and Treatment of Child Abuse and Neglect: Mental Health Treatment Issues And Models
The Role of Mental Health Professionals in the Prevention and Treatment of Child Abuse and Neglect
User Manual Series (1993)
Mental Health Treatment Issues And ModelsProfessionals providing mental health services to children must have a solid foundation in the stages of normal child development and how child maltreatment can adversely affect children's development and behavior. Intrafamilial Child Sexual Abuse Treatment Two important caveats must be presented before discussing therapeutic issues in incestuous families. The first is that insufficient empirical research has been conducted on the effectiveness of interventions with incestuous families, particularly with sexual offenders who are at high risk for recidivism. Second, existing research suggests that incestuous families are a very homogeneous group. There may be many different types of incestuous families that have not yet been identified and grouped at this stage in our knowledge. Regardless of whether different subtypes exist, common themes or patterns of behavior have been identified in the clinical literature. Isolation One of the more common features of incestuous families is the degree to which they are closed off and outside the normal socialization processes that naturally occur with families. This isolation may be the result of poor or underdeveloped social skills on the part of the parents or the family's general avoidance of activities that require them to function in interpersonal relationships. Isolation may also enable perpetrators/fathers to have more control over the family and engage in their abusive behavior within an environment that has a lower risk of disclosure. Alexander suggests that isolation also serves to prevent exposure of family members to healthy, appropriate family models of functioning.40 Poor Communication and Ambiguous Boundaries Within healthy families, one of the important characteristics of family functioning and the development of individuals within the family is communication and the development of specific roles and boundaries within the family. Incestuous families are characterized by limited intrafamily communication such as keeping secrets and not discussing abuse-related behavior and feelings. Family members are not likely to discuss topics such as sexuality, the limits of physical affection, acceptable behavior between siblings, and questionable parental behavior. Incestuous families are also characterized by blurred interpersonal boundaries. Without a clear understanding of the roles and responsibilities of family members (especially between parents and their children), these issues may become ambiguous and more accessible to sexual manipulations. Sexual Distortions Sexual abuse research has consistently reported an intergenerational component associated with child sexual abuse. That is, many children who have been sexually abused may also have one or both parents with a history of sexual victimization in their childhoods. As Finkelhor and Browne point out, one of the common sequelae of child sexual abuse is a pattern of sexual distortions (i.e., traumatic sexualization). 41 This pattern results in confusion about sexual identity and sexual norms, confusion between sex and caregiving, aversions to sex or intimacy, and the conditioning of sexual activity with negative emotions. Parents who were sexually abused as children may have developed distorted images and values about sexuality, which they in turn transmit to their children and partner. Lack of information and confusion about sexuality, including sexual boundaries and limits, and distortions about sexual roles and relationships may foster the development and acceptance within the family of incestuous behavior. Intervention Issues Some key intervention issues in incestuous families include: Assessment of the Child's Immediate and Long-Term Treatment Needs Children may need crisis intervention if the disclosure has just occurred, investigative agencies have just become involved, and a medical examination is required. The trauma of disclosure should not be underestimated, even if the abuse has been taking place over a period of time or occurred long ago. The assessment should include the need for crisis intervention, brief therapy, or long-term therapy to resolve victimization issues. Child's Safety from Abuse As a prerequisite for any type of family therapy or effort to reunify the incestuous family, there must be a focus on the safety of the child, the right of the child to be free from abuse, and the capability of the nonoffending parent to maintain a protective attitude toward the child. Recantation of the sexual abuse allegation by the child can distract professionals from the safety issue. It should not be assumed that because a child recants, the abuse did not happen. Possible reasons for a child recanting include nonsupport or withdrawal of support by the nonoffending parent; pressure by the nonoffending parent, siblings, grandparents, and other relatives to deny previous statements; the child's compassion and need to protect and defend his/her parent; the child's removal from the home and desire to return home under any circumstances; poor intervention and management of the case by investigative agencies; and fear of going to court and testifying. Empowerment of the Nonoffending Parent In many incestuous families the nonoffending parent (typically the mother) is often described as passive, dependent, and nonsupportive of the child. Some mothers may be initially supportive and later withdraw support from the child. Nonsupport by the mother may cause the child to recant his/her report. Supportive interventions are needed to help the mother support the child and establish herself apart from the often dominant partner/spouse. The mother's support may be because of coping style (denial, distancing), prior victimization history, attachment history with her parents and subsequent relationship with her child, emotional distress, mental health/health problems, poor social support, substance abuse, and situational factors related to disclosure of sexual victimization such as criminal and dependency investigations, court appearances, and the breakup of the family structure (e.g., displacement and separation from the partner/spouse, the financial stress of independent living, and the increased responsibilities of a single parent). Management of Sexualized Behavior One of the most common symptoms and concerns associated with child sexual abuse is the premature exposure and expression of inappropriate sexual ideas and behaviors. It may be necessary for the mental health professional to provide sex education to both the child victim and the parents, while supporting the parents' open discussion of appropriate sexuality, sexual feelings, and guidance about sexual behaviors. Skill Building and Education One of the components of treatment must involve breaking down the walls of isolation surrounding incestuous families by developing social and communication skills, building self-confidence, providing assertiveness training, strengthening abilities to identify limits and set boundaries, developing a sense of entitlement, and promoting involvement in extrafamilial activities such as parent groups and school or community organizations. The mental health professional may also need to be a primary source of information and education about child development, sexuality, family values, parenting, and discipline. Status of the Intrafamilial Perpetrator Mental health professionals making treatment plans for children and families in which intrafamilial sexual abuse occurred must know the legal status of the perpetrator (biological father or stepfather). There are at least seven possibilities: (1) the case is pending, the alleged perpetrator is in or out of the home, and the child is in or out of the home depending on the status of the alleged perpetrator; (2) the perpetrator is incarcerated, and the mother is not interested in reunification; (3) the perpetrator is incarcerated, and both parents plan to reunify after release; (4) the perpetrator receives a prison sentence that includes post-release participation in treatment as a condition of probation; (5) the perpetrator is sentenced to weekends or nights in the county jail with participation in treatment as a condition of weekday release; (6) the perpetrator participates in a locally approved diversion program and receives treatment in lieu of incarceration; or (7) there is insufficient evidence to prosecute the case but sufficient evidence for child protective services involvement, and the alleged perpetrator seeks treatment as a condition of family reunification. The following is a brief summary of four issues to consider in providing mental health services if there is a possibility that the perpetrator will reunify with the family. Willingness of the Perpetrator to Assume Genuine Responsibility The principal defense mechanisms employed by sexual offenders are denial ("I didn't do it"), minimalization ("Everyone is making an issue out of this... I only..., It was only..."), and rationalization ("She wanted me to touch her"). Sexual offenders are often highly manipulative individuals and may even see limits as a challenge. Therapists need to be alert and adept at limit setting and must anticipate surface compliance and undermining behavior. Genuine acknowledgment and assumption of complete responsibility for the sexual abuse is the starting point for intervention and the eventual reestablishment of family relationships. The perpetrator needs to demonstrate that he understands and recognizes what he has done, understands the pain he has brought to the child, and desires to have a different, more healthy relationship with the child. This message may need to be communicated several times and in many different ways, and it is also important that the perpetrator demonstrate his commitment to a nonabusive relationship through actions and behaviors (e.g., being responsive to the needs of other family members, participating in ongoing therapy). Awareness and Management of Incestuous Thoughts and Behavior One of the hallmarks of the treatment of sexual perpetrators is the acknowledgment and disclosure of sexual interest in children. As Ryan suggests, the development of sexual interest in children is not impulsive but the gradual shifting of distorted or inappropriate thoughts to behaviors.42 Perpetrators must learn to be aware of both their sexual urges toward children and the thoughts or actions that may lead to inappropriate sexual activities. Behavior modification, anger management, stress reduction, and relapse prevention are essential therapeutic strategies. Highly specialized sexual offender treatment programs have been developed for adults, adolescents, and young children. Pioneering programs for adult sexual offenders first began in the 1950's. Research and treatment programs expanded to include adolescents by the early 1980's. By 1984, the need became apparent to develop programs for children between the ages of 4 to 13 who sexually abuse other children. "Abuse-reactive behavior" is the term now used to describe sexual acting-out behavior of young children who have been sexually abused and now victimize other children.43 Marital Therapy Within the reunifying incestuous family, it is important to reestablish the marital partners as a coalition that works together to meet the needs of the family and protect the child. In those instances in which the marital relationship is viable and the parents wish to continue their marriage, it is important to address marital conflicts and patterns of relationships that may be unbalanced or oppressive. Issues such as marital communication and power distribution within the couple on issues such as conflict resolution, decisionmaking, and sexuality may need to be explored. Reestablishment of the ParentChild Relationship Before reestablishing a parental relationship with his child, the sexual offender must address several fundamental issues with both his spouse and his child. These issues include an examination of trust, betrayal, and a commitment to the well-being of the child; distinctions between physical affection and sexual behavior; assignment of responsibility for the sexual abuse; open expression of affect within the family; and well-defined expectations of sexuality and sexual behavior. Related to this issue are arranged confrontations between perpetrator and child by therapists. This is a controversial issue among experienced clinicians and should not be considered without reviewing the literature and discussing the ramifications with experts. The Comprehensive Sexual Abuse Treatment Program (CSATP) The first prominent model for treating incestuous families was developed by Henry Giaretto, Ph.D., in the mid-1970's and is now called the "Giaretto Model" or Parents United. In response to an absence of treatment approaches to deal with incestuous families, Giaretto developed the Comprehensive Sexual Abuse Treatment Program (CSATP), which consists of:
CSATP has been a well-established model for over 15 years with city, State, and international chapters. Variations of this model have developed over the years; however, the organizing theme of every program is the development of a comprehensive and coordinated approach designed to meet the needs of all of the family members. Local programs' philosophies regarding incarceration and treatment services for the perpetrator are the most frequent reason for the variation in approach. Nonfamilial Child Sexual Abuse: Providing Support To Parents One of the most significant factors in the sexually abused child's adjustment is the level of emotional support from his/her parents. 44 45 Parents need specific information on how to support and provide assistance to their child, how to discuss the incident and future safety precautions, how to respond to the child's questions and feelings, and how to talk to the child's siblings about what happened. Parents may also need to be educated about the importance of respecting children's privacy by telling only selected family members or friends after disclosure to investigative agencies, and prevent inappropriate people from questioning the child about what happened. They also need information about how to anticipate the range and changeability of their own feelings from anger, rage, guilt, and confusion to anguish, disbelief, and blame. They may need counseling to address their own feelings to avoid creating tension, stress, shame, or guilt in their child. Parents may need to discuss feelings of self-blame and recrimination for what occurred, if they blame themselves, or they may need information about the need for parental supervision and selection of appropriate caretakers, if they have been careless. Child Physical Abuse Treatment Components During the last decade, there has been a growing awareness of the multifaceted stress factors that contribute to the physically abusive family. Risk factors include:
Walker, Bonner, and Kaufman have developed a systematic Physical Abuse Assessment Model and a Physical Abuse Process Therapy Worksheet that address the range of risk factors listed above through complete problem identification, problem and strength assessment, planned interventions which correspond to identified problems, and planned use of client strengths.46 Recommended interventions include individual, group, and marital counseling, and parenting education classes with a curriculum that includes anger management and impulse control, stress reduction, increasing self-esteem and coping skills, and child management skills. Some programs and communities also offer parental stress toll-free telephone lines and respite care centers to provide information and relief for parents experiencing stress or other overwhelming situations. The primary focus of many programs is to provide services to the parents. There has been little focus in the clinical literature regarding treatment for severely or chronically physically abused children, including burn victims with disfiguring injury. There are two key intervention issues for abusive parents: Education and Skill Training May Not Be Enough Several research groups point out that education and skill training alone are not enough to remedy child maltreatment. 47 48 49 They stress the relationship between a defective self-image and a reduced ability to cope with crisis and stress. The ability to cope is related to positive cognitive appraisals of oneself, adequate social supports, and knowledge and skills. Nurius, Lovell, and Edgar found that abusing mothers on a self-concept appraisal scale tended to view themselves in one-dimensional, fixed ways (e.g., "It's just my nature" "I guess you are who you are and that's it") and with negative self-attributes such as being impatient, ineffective, and out of control.50 These authors recommend that detailed attention to self-appraisal be part of the assessment process prior to treatment and that building positive self-appraisal is a critical step to increasing the parent's ability to cope with stress and remain in control. Aggression Management Wolfe reports that establishing inhibitory controls for aggressive behavior such as relaxation and stress management is a key factor in treatment for abusive parents.51 His associates found evidence of greater levels of physiological arousal in the face of child-related stress among abusive parents than in non-abusive parents.52 Since emotional arousal facilitates the development of aggression, this may suggest that parents' emotional arousal may contribute to a physical assault on their children.53 Abusive parents participating in a 13-week treatment program reported significant changes in their interactions with their children. The treatment program adopted the multimethod approach recommended by Novaro,54 which included anger management training to reduce physiological arousal; training in communication skills and problem-solving skills to improve interpersonal and parenting skills; and training in developing an empathic response to children by enabling parents to see the child's perspective, to see the child as an individual and not an extension of themselves, and to accurately interpret the child's intentions. Self-Help Groups Self-help groups first emerged in the United States in the 1920's, the best-known examples of which are Alcoholics Anonymous and Gamblers Anonymous. The first self-help group for abusive parents, Parents Anonymous, was established in 1970 by a mother, Jolly K., who found that traditional psychotherapy was not enough to deal with her abusive tendencies. After that first group was formed, Jolly K. and the Parents Anonymous model's co-founder, Leonard Lieber, L.C.S.W., went on to develop groups and chapters throughout the United States as well as worldwide. In general, self-help groups comprise individuals with a common experience or problem that they are trying to resolve, recover from, or handle in new and constructive ways. These groups can be described as having one of two goals: to bring about a change in behavior or to enable members to constructively adapt to life experiences or change. The first type of group focuses on the need to modify or control members' attitudes, behaviors, and effects on others. These organizations provide intensive support systems that reinforce the importance of the members' behavior change. The second type of self-help group focuses more on adaptation and coping through internal attitudinal, behavioral, or affective changes. The goal of these groups is adaptation to major life changes or events such as death, catastrophic accidents or illness, or victimization experiences. Parents Anonymous Model Parents Anonymous has chapters in many communities that provide groups for parents and treatment groups for children to reduce and prevent child abuse. The Parents Anonymous model works best for parents who are more "explosive" in their behavior or those who have physical and verbal or emotional abuse problems. This model operates support groups, at no charge to members, that have a volunteer professional sponsor with expertise in the provision of psychological or social services. The sponsor is involved as a group consultant and as a resource for the parentchairperson who leads the group. An important role of the sponsor is to function as a positive authority figure. In this role, the sponsor can identify and refer members who need additional services such as individual therapy or family counseling. The sponsor also serves as a role model or positive authority figure for members who have abusive experiences with caretakers. In this capacity, the sponsor can facilitate the resolution of individuals' reactions toward past authority figures and learn to incorporate new ways of being positive authority figures in their children's lives. Several factors have been identified as the reasons for the success of self-help groups in modifying behavior:
Neglecting Families: Intensive In-Home Interventions Intensive, in-home therapeutic counseling and social services have been found to be most effective with neglecting families. The primary goals of these services are to improve parents' abilities to raise their children in a healthy environment, keep families intact through supportive services, and reduce the risk of an out-of-home placement for children. These services are designed to improve family coping skills and functioning, provide emotional support to parents, model problem solving to cope with everyday problems and parentchild interactions, promote positive parenting skills and optimal child development, and teach household management skills, including nutrition and financial management. The programs' "parent the parent" strategy allows initial dependence before encouraging independence. "Do for, do with, cheer on" describes the philosophy and approach of these programs. These types of programs may be called by a variety of names, including "Family Preservation," "Homebuilders," "Family-Centered Services," "Home-Based Services," "Intensive Family-Based Services," and "Home-Based Treatment." The general characteristics and features of these programs include:
Each worker carries a small caseload--from one to three families at any given time.A general perspective of family preservation programs is to work with family strengths and include the use of the extended family, community, and neighborhood resources.57 Numerous theoretical approaches have been described as being part of family preservation services including crisis intervention theory, family systems theory, and social learning theory.58
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