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: Treatment Modalities

The Role of Mental Health Professionals in the Prevention and Treatment of Child Abuse and Neglect
User Manual Series (1993)

Author(s):  U.S. Department of Health and Human Services Peterson, Urquiza

Year Published:  1993

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You are in section: Table of Contents Preface Acknowledgments 1 - Introduction 2 - Working With Abused And… 3 - Responsibilities Of The Mental… 4 - How Child Abuse And Neglect… 5 - Mental Health Treatment… 6 - Treatment Modalities Notes Selected Bibliography Other Resources Glossary of Terms Appendix A - Crime Victim… Appendix B - List Of Other User…

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Treatment Modalities

The process of determining the most appropriate type of intervention is based on the mental health professional's assessment of the child, parents, and family. The organization and delivery of treatment services are also affected by public funding of mental health clinics and treatment services, health insurance benefits, access to health insurance, and eligibility for treatment under Victims of Crime Programs. Some considerations for individual therapy include:

• Child characteristics: Age, verbal ability, emotional maturity, presence of a developmental disability, social skill level, and the impact of the problems on the child's social adjustment.
  
  
• Parental characteristics: Emotional immaturity, concrete thinking versus insight-oriented individuals, motivation, or the presence of a developmental disability.
  
  
• Nature of the presenting problem: Mental health issues (e.g., depression, schizophrenia, anxiety disorder; personality disorder; substance abuse), self-esteem issues, sexualized behavior, enuresis, or urgency of intervention required (e.g. suicidal or self-destructive problems).
  
  
• The lack of organization of the family: Whether parents are able to appear for scheduled appointments at an office. For example, many families may not have the finances and/or ability to come to therapy on a weekly basis. In such cases, alternative interventions, such as intensive home-based services have proven most effective with neglecting families or chaotic, disorganized families.

Indications for family therapy include:

• Dynamics of family communication and family interpersonal relationships: Whether the family should be seen together or in dyads to improve relationships. Family therapy is helpful in addressing family system dynamics, communication problems, imbalanced relationships, feelings of abandonment or distrust, or problems in the expression of emotion.
  
  
• Low level or no support for the child: Acknowledgment that the child has been victimized, belief in the child's reports of abuse/disclosure, or blame placed on the child.
  
  
• The presence of behavioral problems or symptoms with siblings: Involves siblings who may also have been physically and/or sexually abused and may have parallel issues which need to be addressed within a family setting.
  
  
• Child's age: Addressing the problems of young children typically requires significant parental involvement, whereas older children (e.g., teenagers) are more able to benefit from individual or group therapy approaches.

Indications for group therapy include:

• An assessment that the client would benefit from being part of a group that shares a common condition and can understand one anothers' experience. This experience, often referred to as "universality," reduces isolation and the sense of being "different." Participation in a group also enables the client to interact with group members who have resolved some issues and "moved on" as well as with others who are struggling with issues the client may have mastered, thereby enabling the client to lend insight and support to others.
  
  
• A group therapy approach is typically not recommended for a child's first encounter with therapy for child sexual abuse, physical abuse, and/or neglect. Many of the issues that children initially encounter in dealing with their victimization are too personal, embarrassing, and painful to disclose and discuss within a group therapy setting. Group therapy is usually indicated for children who have first been involved in either individual or family therapy and have addressed many common abuse-related issues (e.g., distrust, betrayal, problems with self-esteem, stigmatization).⁵⁹
  
  
• Age and development are important considerations for selecting a group therapy approach. Children with poorly developed expressive and receptive language skills may have difficulty with a group therapy format. Similarly, many of the essential elements of "attending" within a group are not adequately developed until at least the preschool years. Very young children may not be able to verbally facilitate and process much victimization information and affect. A group therapy approach to dealing with victimization issues is more appropriate for school-age children and teenagers.
  
  
• Group therapy may be particularly helpful for children and adolescents who need assistance in seeking validation and support. The process of disclosing victimization experiences and feelings may alleviate children's perceptions of themselves as different, stigmatized, and "damaged."
  
  
• Group therapy is typically not indicated for children who have behavioral problems, which may interfere with their ability to participate or their ability to be supportive to other group members. This may include children who are hyperactive, aggressive, abusive, or sexually acting­out. It should be noted that while children with these types of problems may not benefit from group therapy approaches for victimization issues, they may require a group approach that is more specific to their needs (e.g., groups for children with sexual behavior problems).

Dealing With The Justice System

It is not unusual for maltreated children and their families to be actively involved with either the Criminal, Juvenile, or Family Court during the course of therapy. The investigation, law enforcement or investigative social worker recommendations, prosecution, hearings, trials, and court outcomes can have a significant impact on the child and family members' emotional, cognitive, and daily functioning. To be effective, mental health professionals must know the status of their client's involvement in the investigative process or court system and work to facilitate both the client's cognitive understanding of this process and the management of his/her emotional reactions. Mental health professionals must have knowledge of terminology, roles of criminal justice and child protective services personnel, and local procedural steps and practices.

This knowledge enables the therapist to educate and clarify the client's information and understanding of what is taking place; support the client to obtain assistance or timely, responsive, and appropriate treatment; advocate for the client or serve as a liaison between investigative personnel and the child or child's family, if indicated; and help clients cope with court decisions that can change their lives either temporarily or, in some cases, permanently.

The therapist can provide advocacy and advice on child protection issues such as:

• the need to place a child in foster care, prevention of multiple placements, or the need for a change in placement;
  
  
• informing and preparing the child for a foster care placement or a change in placement;
  
  
• assisting the social worker, foster parents, or parents in managing the child's behavior during a transition to foster care or in returning home;
  
  
• making recommendations to social workers about visitation or family reunification decisions;
  
  
• discussing fears and concerns about court procedures and potential case outcomes, and ways to manage emotional reactions to possible case outcomes;
  
  
• preparing the client to manage the stress of court testimony.

The priority is to advocate in the best interests of the child by taking into consideration the child's safety, emotional, and developmental needs. This statement is frequently made and defended from the perspective and context of the person proposing or defending a recommendation. In most of these situations, there are many competing priorities, (e.g., child's needs, parents' desires versus their actual capabilities, investigative and judicial procedures, and local and State policies regarding foster placement and level of care). The safety of the child immediately followed by the emotional and developmental needs of the child should take precedence.

Managing The Therapeutic Environment

Appropriate management of the therapeutic environment supports many aspects of the therapeutic relationship and incorporates a diverse set of characteristics that includes the physical environment, support personnel, and structure of the therapeutic session.

Physical Environment

The physical environment is important to provide a sense of security to the child and family. Therapists should plan to create an atmosphere in which the child and family feel that they are safe, with ample opportunity provided for expressing their concerns, and an environment free of interruption and unnecessary risks and hazards to children (e.g., breakable objects that require constant child monitoring), or hazardous elements (e.g., uncovered electric sockets).

Support Personnel

The first and last agency contact is often with a receptionist or secretarial support person. This individual is in a unique position to provide an atmosphere of warmth, acceptance, and congeniality. In some cases, children or their parents may feel a sense of shame, isolation, or stigmatization as a result of either being maltreated or being involved in therapy. The value of friendly and attentive support personnel cannot be overestimated.

Structure of the Therapeutic Session

Establishing a specific format or routine can facilitate the child or family's ongoing resolution of clinical issues. Children often need physical structure to facilitate their involvement with the therapist and to remember the tasks or objectives of the therapy. By establishing a regular routine, the client develops expectations about the therapist and the therapeutic process, may feel less threatened about involvement in therapy, and more secure about therapy sessions. An example of such a routine related to the structure of the therapeutic session involves the process of greeting the client in the waiting room, walking with the client down the hall, entering the therapy room together, and beginning the session with a similar question or activity (e.g., a question related to issues that may have occurred since the last session or starting a session by playing with a particular toy). This structure also includes setting a specific and acknowledged time for the duration and frequency of sessions.

Confidentiality

Clients need to trust mental health professionals, feel free to confide information and concerns, and feel comfortable exploring difficult issues and subject matter. Explaining confidentiality to children and parents will facilitate their understanding of the scope and purpose of evaluation and clinical services. Explanations to children must be tailored to their level of understanding. The statutory duty to report child abuse and neglect, however, is not excused by the patient­psychotherapist privilege. In statements about confidentiality, mental health professionals should be certain that their clients are aware that the following must be reported if they are suspected:

• child abuse, sexual abuse, or neglect;
  
  
• threat of suicide or attempted suicide; or
  
  
• homicide or threat of homicide.

It is recommended that parents and children be given a confidentiality statement at the beginning of therapy, that the statements be made both verbally and in writing, and that the statements be included with other guidelines regarding the therapeutic relationship. Suggested verbal statements for both a parent and a child are:

• To Parent: "What we discuss in therapy is confidential with two exceptions: one, if I think you're going to hurt yourself; two, if I think you're going to hurt someone else, including your child. If either of these two events seems likely, I will need to take protective action, which will include calling appropriate authorities."
  
  
• To Child: "What we discuss in therapy is confidential with three exceptions: one, if I think you're going to hurt yourself; two, if I think you're going to hurt someone else; and, three, if I think someone or something is hurting you, including your parents. When any of those things are going on, I'll need to let someone know and try to get additional help for you." ⁶⁰

Release of Information

Clients often feel more comfortable talking about issues and their behavior when they know that clinicians do not talk about their clients outside the clinical setting and understand the conditions and procedures for release of information. In forensic evaluations, clients must be informed about the nature of the evaluation and that the information will be given to the investigative agency requesting the evaluation. In clinical evaluations and treatment services, clients should be informed that information can be released or exchanged only after a consent form is signed. States' laws regarding the possibility of mental health records being subpoenaed should also be explained to clients.

Personal Issues For Mental Health Professionals

Countertransference

Countertransference has been identified and described in the writings on psychoanalytic and psychodynamic theory, but only recently has this internal reaction of therapists been specifically discussed in the child maltreatment literature.⁶¹ Countertransference is defined as the therapist's reactions (feelings, thoughts, statements and behavior) directed toward the client and brought about by the therapist's previous life experiences. A therapist's countertransference reactions may be generated by an aspect of the client's history, the client's presentation, or the interaction between the client and therapist. Examples of factors that may influence the therapist's reactions when working with abused and neglected children and their families include:

• a previous history of child maltreatment;
  
  
• early childhood relationships with parents and caretakers;
  
  
• existing relationships with his/her own children;
  
  
• interactions with the client–child, parent, or family; and,
  
  
• previous clients with similar clinical or historical features.

Countertransference is significant in any therapeutic context because it can affect the quality and direction of the psychotherapy. Awareness of the issue is important in providing clinical services to abused and neglected children and families, especially if the therapist has a history of child maltreatment. Some mental health professionals suggest that therapists who have experienced child maltreatment may have inherent difficulties in managing their own reactions. Examples of their concern include biased interpretations of children's behavior, anger toward abusive parents, a perceived lack of participation or progress on the part of the abusive parent, limited or inappropriate interventions with abusive parents, and biased rather than objective recommendations for removal of children from their home or for family reunification.

Further examination of the manifestations of countertransference in psychotherapy with abused and neglected children and their families is needed. Friedrich suggests that therapists often have difficulty with countertransference when they become too rigid in their approach, have numerous unresolved victimization issues, and begin to define themselves as successful only through their therapy.⁶² The key to identifying and resolving countertransference issues is the therapist's ability to use the information he/she observes (i.e., think, feel, and/or see) about him/herself in the therapeutic relationship. For example, a therapist who feels deeply saddened as a result of interacting with a client and begins to divert his attention to his own feelings cannot adequately respond to his client. The alert therapist identifies and manages this internal response and converts it toward a sensitive intervention with the client.

Therapists must be alert to countertransference and its impact on their therapeutic interventions. It is helpful to discuss them with a clinical supervisor or colleague to develop objectivity. There is no indication that a therapist with a history of child maltreatment should not work with abused children and their families as long as potential countertransference reactions are identified and the issues are managed in a way that is beneficial to the client.

Stress and Burnout

Stress and burnout occur in many professions. Working with abused and neglected children and the limitations of the systems designed to help them, however, present a unique set of stressors. Stress and burnout are the most commonly recognized terms to describe professionals' reactions.

Stress is viewed as having physiological, behavioral/emotional, and cognitive components. Physiological reactions can include tightness in the chest, stomach aches, intestinal or bowel problems, hyperventilating, decreased immunity, high blood pressure, or exhaustion. Behavioral reactions can include insomnia, avoidance (arriving late at work/leaving early, disappearing during the workday, noncompletion of assignments); low frustration tolerance (becoming easily emotionally reactive to situations or being short-tempered); or scapegoating other employees or agencies. Emotional reactions include feelings of sadness, anxiety, depression, and feeling lonely and overwhelmed. Examples of cognitive distortions include "all or nothing" thinking, overgeneralization, exclusive focus on the negative and disqualifying the positive, magnifying problems, and feeling responsible for problems without examining whether or not they belong to someone else.⁶³ Burnout is viewed as the result of failing to cope successfully with stress. Freudenberger suggests that burnout may be manifest as "waning enthusiasm, irritability, and feelings of disengagement caused by stress, pressure, and exhaustion."⁶⁴

Sources of stress most commonly reported in the field of child abuse and neglect are repeated exposure to children's histories of cruelty, abuse, and neglect inflicted by caretakers and the children's adaptations; the realities of working with chaotic, disorganized families or families with abnormal relationships; overwhelming caseloads; anxious, demanding nonoffending parents and relatives; the limitations of the law, the criminal justice system, and social service agencies designed to help children; constantly feeling "unfinished" about work; social policies driven by fiscal resources; feeling unable or unwilling to talk about cases with friends or family; lack of coordination and/or cooperation among public agencies; and agencies and organizations unresponsive to employee stress.

New literature is beginning to evolve on the unique stress experienced by professionals working with victims of trauma. Figley⁶⁵ has coined the term "secondary victimization" and McCann and Pearlman⁶⁶ have described it as "vicarious traumatization." Both concepts describe the psychological reactions of professionals to working with crime or trauma victims.

Managing Professional And Private Lives

To help prevent secondary victimization and burnout, the mental health professional should:

• separate his/her personal and professional lives by balancing work and recreation;
  
  
• develop absorbing interests and friends outside the field;
  
  
• engage in regular physical activities such as walking, swimming, sports, gardening, etc.;
  
  
• take real breaks during the day;
  
  
• balance trauma work with nontrauma work, clinical work with nonclinical work (such as teaching, consultation, or research), or direct service with administrative activities;
  
  
• attend professional meetings, conferences, and workshops not only to build skills but to develop supportive professional contacts and restorative breaks from the ordinary;
  
  
• assess the possibility of a personal basis for workaholic tendencies, (e.g., low self-esteem, unresolved victimization, dissatisfying personal life);
• avoid overcommitment and overextension of work-related activities for prolonged periods of time, (e.g., years);
  
  
• meet regularly with other professionals either from the same discipline or from related disciplines to share perspectives and feelings (they may be more supportive than friends or relatives who do not want to hear about the details of this work or cannot understand why mental health and other professionals serving abused and neglected children choose this type of work); and
  
  
• establish attainable goals for the week, month, or year and write them down (professionals in this field should avoid the quagmire of "I am not doing enough," with no means of comparing these thoughts to a realistic, measurable list).

Responsibilities Of Supervisors, Managers, And Administrators

Supervisors, managers, and administrators have a responsibility to their employees to create a supportive work environment for staff. Unfortunately, work-related stress has historically been viewed as the employee's problem. Stress from working with abused and neglected children should not be treated as business as usual or burned-out employees as front-line casualties.⁶⁷ Managers should consider the following steps to build a positive, supportive organization:

• Assess how well the organization recognizes and responds to the levels of stress experienced by its employees. Are there methods to help people cope built into daily operations? Do any policies worsen the stress employees feel? Symptoms of dysfunction include low morale; high turnover; absenteeism; scapegoated, angry, and frustrated workers; mistrust of management; and lack of cooperation among staff.
  
  

• Assess whether the basic causes of job stress exist, such as unclear job descriptions and unrealistic expectations regarding the scope and responsibilities of the position; conflicting workload demands and priorities; an inability or resistance on the part of management to clarify priorities; persistent job overload in which employees have more to do than what they can reasonably accomplish; and lack of problem resolution and employee frustration over problems and issues that constantly reoccur because they are unresolved.
  
  
• Discuss the problems with employees to obtain their perspective. Develop action plans to address the issues and keep employees informed about progress toward resolution as well as about obstacles and setbacks.
  
  
• Identify and reduce employee isolation by encouraging camaraderie and the development of a common base of experience through informal and formal group activities. Promote consultation, problem solving, and decisionmaking to both reduce the burden on individual employees and encourage the creation of new approaches and alternatives.
  
  
• Provide consultation and regular supervision for employees to reduce feelings of isolation, recognize work-related stress, and validate employees and their work.
  
  
• Create an environment in which employees feel valued and their work is recognized. Celebrate accomplishments, no matter how small or incremental. Involve employees in planning and implementing activities that will make them feel supported and appreciated. Build intra-agency support systems so that employees feel part of a broader network of professionals striving to serve the target population.
  
  
• Assert and act on the belief that the mental health and personal effectiveness of employees are as important as the needs of the clients they serve.

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You are in section: Table of Contents Preface Acknowledgments 1 - Introduction 2 - Working With Abused And… 3 - Responsibilities Of The Mental… 4 - How Child Abuse And Neglect… 5 - Mental Health Treatment… 6 - Treatment Modalities Notes Selected Bibliography Other Resources Glossary of Terms Appendix A - Crime Victim… Appendix B - List Of Other User…

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Updated on October 9, 2009