The high prevalence of histories of childhood abuse among
individuals with substance abuse disorders, as well as their
frequent need for mental health services, has important implications
for treatment planning and implementation. Moreover, as mentioned
in Chapter 1, clients with substance
abuse disorders who were abused or neglected as children may
be more prone to relapse than those without such histories.
The Drug Abuse Treatment Outcome Study (DATOS) (Craddock
et al., 1997) found that an important factor in predicting
treatment success was the number of services received, such as
case management, parenting education, and counseling for childhood
abuse and posttraumatic stress disorder (PTSD). Clients receiving
additional services such as these were statistically more likely
to stay in recovery.
Some estimates suggest that up to two thirds of all those
in substance abuse treatment report that they were physically,
sexually, or emotionally abused during childhood (Swan,
1998), whereas as many as 80 percent of people referred to
mental health services have histories of childhood abuse (Briere, 1992a; Briere and
Woo, 1991; Briere and Zaidi, 1989).
Because an abuse history and a diagnosis of PTSD increase the
risk of relapse, it is advisable to address these issues at some
point during the course of substance abuse treatment. Although
many clients need to address substance abuse issues before they
are able to receive and benefit from treatment for past trauma,
some need attention to the trauma before they can achieve sobriety.
For some, it is during sobriety when they begin to experience
symptoms of PTSD (such as flashbacks and nightmares) or recall
memories of long-forgotten or repressed experiences of past abuse.
As these uncomfortable and sometimes debilitating symptoms and
memories emerge, many individuals return to using substances
in an attempt to suppress their problems and manage their emotional
pain.
For example, Department of Veterans Affairs facilities often
require a minimum of 30 days of abstinence before veterans can
receive treatment for PTSD. If abstinence can be achieved and
maintained without directly dealing with traumatic issues, it
should be encouraged because abstinence will likely better prepare
clients to face issues related to past trauma. However, if clients
mention traumatic issues or suffer from intrusive memories or
other reactions related to the trauma, the counselor should be
prepared to address them, initially from an educational perspective
that offers clients reassurance.
Counselors would do well to become familiar with the many
ways in which childhood abuse and neglect issues can manifest
themselves during clients' treatment. At the same time, they
must remain open and ready for any possibility, realizing that
disclosure does not always happen as one might expect. All clients
need to work at their own pace. This is especially true for
those with a history of childhood abuse or neglect, for whom
disclosure of the abuse may take years.
Clients may enter substance abuse treatment for any number
of reasons, ranging from self-diagnosis to mandated treatment
for those referred by the criminal justice system. Whatever
the reason for entering treatment, it is not unusual for a client
to first identify or disclose a history of childhood abuse when
in treatment. Counselors should understand that identification
and disclosure of an abuse history occur in a variety of ways
and for a variety of reasons. As discussed in Chapter
2, it is recommended that all psychosocial assessments include
questions about past abuse and trauma and that questions be asked
in behavioral terms to increase clients' understanding (i.e.,
"Were you struck or beaten as a child? Were you physically hurt
as a result of someone hitting or beating you? As a child, did
you ever have a sexual experience with an adult or a relative?").
Such direct questioning often prompts disclosure of past abuse;
however, some individuals with positive abuse histories do not
disclose because of feelings of shame, mistrust, or fear, or
because they downplay their experiences by labeling them as normal
and deserved and therefore not abusive. Others disclose only
when issues concerning the abuse of their own children are raised.
Acknowledging past abuse can be an important step for clients
in treatment because it breaks the secrecy and shame that are
so often part of the abuse legacy. Many clients may find it
easier to "confide" their history to a computer screen or a piece
of paper than to another person. For some clients, the act of
acknowledging is so relieving that it is healing in and of itself.
However, for most, acknowledgement alone is not enough and requires
additional therapeutic work for full resolution of abuse-related
issues.
Once abuse history has been disclosed, it is important that
it be acknowledged and not dismissed by the counselor. Counselors
should be aware that clients may be hypervigilant regarding counselors'
reactions to their experiences. Clients may interpret seemingly
insignificant behaviors as signs of blame or rejection and may
need considerable reassurance from the counselor that she does
not hold them responsible for the abuse or view them differently
because she knows about it. Sometimes, clients will project
personal discomfort about discussing the abuse onto the counselor
and may need to hear that the counselor is willing and able to
discuss abuse issues without becoming overwhelmed or rejecting
the client.
Counselors should understand how to relate to clients sensitively
and in a way that does not exacerbate long-standing emotional
wounds. For example, as children, clients may have been punished,
shut out, or sent away from the family when they attempted to
tell someone of sexual abuse. If a counselor is too hasty in
making a referral for childhood abuse issues after clients have
confided their experiences, old feelings of rejection and abandonment
can resurface, with the clients perceiving that they are once
again being "sent away" for telling about the abuse. Even if
there is no such suggestion, clients may become withdrawn after
having been so vulnerable.
The counselor should be aware not only of this possibility
but also that the clients themselves may not be consciously aware
of or show any anxiety over these feelings.
Talking to a sympathetic listener can be an important first
step for abused clients to begin the healing process. In the
initial crisis that often arises from disclosure, the counselor's
most important tasks are to reassure clients of the safety of
the treatment environment and to actively teach techniques for
safety and the safe expression of feelings in everyday life (see
"Dealing With Disruptive or Dangerous Behavior" in Chapter
4). Additionally, the counselor may need to respond to any
active crises. Some clients require medical supervision in inpatient
or intensive outpatient programs (at least during the early stages
of abstinence) as they deal with their intense feelings of rage,
anxiety, depression, or their debilitating symptoms, including
impulses to harm themselves or others. The treatment provider
should make clear to clients that they now have the capacity
to deal with traumatic memories and related destructive behaviors
stemming from childhood abuse which they lacked as children.
The counselor can help clients by providing a structured environment
in which they can assess their feelings on a daily basis. One
way to do this is by helping them reflect each day on what their
needs are for that day--for example, rest and exercise--and how
well they are meeting and addressing those needs. Encouraging
clients to write in journals can be a helpful technique. For
example, writing about an anger episode in a personal journal
can be useful for clients with rage issues (Potter-Efron
and Potter-Efron, 1991). Describing incidents of anger can
help these clients gain a degree of distance from their rage
and evaluate the effectiveness of how they typically deal with
anger.
Although the primary focus of the treatment will be on substance
abuse, the counselor should incorporate issues related to abuse
and neglect into the treatment as needed. In acknowledging clients'
childhood abuse and neglect, the counselor must validate clients'
experiences by recognizing the issue. In this process, clients
are helped to remember more (if they desire) and express their
feelings. They can come to recognize themselves as victims,
rather than the cause of the abuse, alleviating the feelings
of guilt and shame that abused children typically take upon themselves
and carry into adulthood. Through empathic listening, the counselor
can help clients develop internal control by acknowledging their
histories of abuse in order to move on. For instance, the counselor
can point out to clients that the mere act of walking into the
counselor's office and the very fact that they function despite
their histories of abuse are important signs of strength. The
counselor must actively acknowledge these strengths. If nothing
else, the counselor is effecting a positive intervention by creating
an environment that allows this process to take place.
How or when abuse issues are incorporated will vary with the
needs of the clients (as determined by the initial and ongoing
assessments) and by the treatment model espoused by the treatment
facility or individual counselor. As a preliminary step, the
counselor can educate clients about the possible impact of abuse
and neglect in general and as it pertains specifically to the
substance abuse disorder. Such an educational approach can be
immediately therapeutic because it can help clients understand
and normalize responses and symptoms. Traumatized and substance-abusing
individuals often believe that their symptoms mean that they
are crazy or are going crazy. Learning that certain effects
and symptoms are part of a predictable and normal course of reactions
can be very relieving and in some cases can stimulate the recovery
process.
Counselors can explain the treatment process itself and when
it will be necessary to address abuse issues as part of treatment,
which constitutes part of the informed consent process. Involving
and informing clients of this process make them more invested
in their own treatment. They can be invited to work collaboratively
with the counselor about whether and when to address issues related
to childhood abuse in their treatment for substance abuse. A
collaborative stance engages clients in problemsolving and indicates
that they have some control in the process. Such a stance has
the effect of countering the lack of control that occurs with
abuse and neglect and thus can also have a direct therapeutic
benefit.
Last, the counselor has to be a consistent presence for clients
and must respect the clients' confidentiality. Many clients
who have been abused direct their feelings of anger and rebelliousness
against any adult figure, including the counselor. The counselor
must carefully pace the clients' treatment by monitoring anxiety
and depression levels and by taking other cues directly from
the clients.
The anxiety and feelings of pain that might surface when a
client becomes more aware of past abuse are often related to
PTSD, and selected psychiatric medications may be required to
help the client through this painful period. Because some clients
may have self-medicated with substances does not mean that they
have no legitimate need for medication. The use of medications
as a specific treatment technique is a potentially troubling
strategy for some alcohol and drug counselors; however, it is
routinely assessed for use with abuse and trauma disorders because
of the high co-morbidity of debilitating depression and anxiety.
Obviously, this approach--as an aid to stabilizing clients for
other therapeutic interventions--should be used only after careful
assessment and with prescriptions written by a medical professional
who is aware of addiction issues.
Many programs use a sequential model of treatment,
in which a period of abstinence is required before a client can
move on to psychotherapeutic treatment of issues related to childhood
abuse or neglect. Many treatment providers associated with programs
of this sort believe that psychotherapeutic intervention for
issues surrounding clients' abuse history cannot be effective
until the client has maintained abstinence for some period.
During the time that the client is achieving abstinence, the
counselor can gather information about relevant psychological
issues, including those related to a history of abuse and neglect,
which can then be passed on to a mental health practitioner when
formal psychotherapy is undertaken. An important exception,
however, is in cases of ongoing violence either directed toward
or perpetrated by the client. In recent years, as alcohol and
drug counselors have recognized the significant overlap between
the addiction and abuse populations and their treatment issues,
many have come to believe that people who have suffered severe
abuse and neglect as children may not be able to stop abusing
substances until they deal with abuse issues early in the treatment
process. Two treatment models of this sort are available--the
integrated model and the concurrent model.
In the integrated model, which addresses dual diagnosis
(i.e., substance abuse and mental health treatment), both substance
abuse and childhood abuse or neglect are treated in the same
program. The provider might also serve as a mental health counselor
or address abuse issues from a psychoeducational perspective
in conjunction with the substance abuse treatment. A comprehensive
dual diagnosis model of this sort (labeled "the dual recovery
model") has been proposed (Evans and Sullivan,
1995).
In a concurrent treatment model, referrals are made
as appropriate for needed mental health services while the substance
abuse treatment continues. In this model, staff members who
are not substance abuse treatment professionals may deliver mental
health treatment. In any situation where clients are receiving
services from different providers, all parties involved should
work together to act in the best interests of the clients.
The Consensus Panel believes that each case must be evaluated
separately. There will be cases in which clients need to address
an underlying mental disorder before they are capable of maintaining
abstinence, as well as times when an extended period of abstinence
(from 6 months to a year) will be required before clients are
ready to address past trauma. This issue continues to be a subject
of debate, especially since third-party payors generally allow
a limited number of visits for substance abuse treatment (Marlatt and Gordon, 1985). Regardless of
how treatment is structured, a comprehensive assessment is needed
first to determine what kind of treatment is most appropriate
and to systematically address the needs of the individual client.
The type of treatment that is most suitable to the individual
can be determined in a number of ways. Although traditional
12-Step approaches emphasize a linear model of recovery in which
abstinence takes priority over all other issues, research data
are not yet available to indicate the superiority of this approach.
Yet, even if the linear model is the superior one, a reasonable
compromise is needed for issues of childhood abuse and neglect.
The overlap between addiction and violence in families should
be discussed throughout treatment, in conjunction with more customary
discussions about dysfunctional families and family roles. Addressing
multiple issues simultaneously rather than in a step-like manner
may actually be indicated and potentially more effective for
many people.
If an individual has active and acute trauma-specific (i.e.,
PTSD) symptoms, in most cases it is optimal to address them immediately
so they do not interfere with the client's ability to establish
and maintain abstinence. If an individual does not have acute
or debilitating symptoms, he may be able to establish abstinence
before addressing trauma-related concerns. If he fails to establish
abstinence first, despite indications that a non-trauma-focused
treatment seemed most appropriate initially, then that may indicate
the need to address trauma issues first.
In addition, direct therapeutic intervention for childhood
abuse and neglect issues will often have to be included at some
point in treatment, although precisely when depends on the needs
and status of the clients. The first stage of substance abuse
treatment occurs during detoxification and the first 30 days
afterward, the period in which clients are becoming engaged in
treatment. In-depth attention to issues of childhood abuse and
neglect is generally not appropriate during this stage. The
second stage of recovery may last anywhere from 30 days to 2
years, during which clients are establishing new and "sober"
relationships, securing employment, participating in support
groups such as 12-Step programs, and possibly reconnecting with
family. During this second stage, clients may feel a need to
address childhood abuse and neglect issues but should not be
expected to do so. The third stage is, in many ways, the rest
of the clients' lives, during which they are recovering from
their substance abuse disorders. In this stage, clients generally
can better deal with a broader range of issues.
Although progress through these stages can differ substantially
for each client, the primary focus of treatment can be expected
to change eventually from substance abuse to other psychological
issues such as those associated with childhood abuse and neglect.
For some clients, this transition can occur relatively early
in treatment; for many others, these issues will need to wait
until sobriety has been achieved and they have spent some time
working on issues surrounding their substance abuse.
Whatever the sequence and time, it can be very helpful to
ask clients to identify the issues to be addressed and in which
order, and to develop short- and long-term goals for doing so.
Such a treatment plan would also address what steps clients
need to take to implement the plan and the identification of
potential relapse triggers. For clients who are not yet stable
in their recovery or who cannot yet tolerate such exploration,
developing such a plan helps maintain their focus on immediate
recovery issues and establish some direction regarding when and
how to address childhood abuse in the future. It also assists
in redirecting clients who are insistent on working with abuse
and trauma-related issues at the outset of treatment, before
sobriety is achieved. The counselor should understand and empathize
with the clients' sense of urgency. Clients may be desperately
trying to get rid of profound emotional pain and debilitating
symptoms. The counselor must be able to express an understanding
of the clients' urgency while simultaneously encouraging them
to "stay the course" and to "make haste slowly;" that is, address
abuse and trauma issues at a pace that is tolerable and that
does not lead to regression or relapse.
Clients may approach treatment with a great deal of mistrust
and skepticism. They might start by asking the counselor such
questions as, "Can you promise me that my life will be better
if I stop using, or if I face my abuse and trauma issues?" In
the short term, self-medication with substances may seem overwhelmingly
preferable to a distant (and perhaps unimaginable) time when
life will be better without them. Clients may think that the
counselor wants to take away their primary means of coping, leaving
them unable to function because of the severity of their emotional
pain and symptoms. Therefore, the counselor must search for
and apply any available leverage to help motivate clients for
treatment while getting through the short-term pain until some
treatment benefits can be realized. Clients must be engaged
in a way that will give them hope and increase their beliefs
in their own power to overcome and resolve abuse issues to create
a new life.
Some clients may actually succeed in stopping their substance
abuse without relapsing but without apparently ever confronting
their childhood abuse issues. It should not be assumed that
such clients have not dealt with those issues; in some cases
they may simply have not done so openly. In other cases, these
clients may not be ready to discuss issues of abuse and trauma.
In still others, clients recoil from emerging memories of abuse
and may need to recant (often several times over) and struggle
with the possible reality of their memories before arriving at
a point of acceptance. Such "resistance" functions as protection
and often yields as clients become less vulnerable and more able
to face and accept the situation. Clients should never be forced
to confront these issues if they do not feel ready. Forcing
clients to do so may recreate an abusive situation and retraumatize
the client. It is also important for the counselor to accept
that some clients may not require or desire intense focus on
abuse issues in order to facilitate their substance abuse treatment.
The determination of whether to address childhood abuse is often
dependent upon the clients' symptoms and ability to stay sober
and is ultimately the client's and not the counselor's choice.
It is noteworthy that this sequenced model of treatment is
consistent with the contemporary treatment model for posttraumatic
conditions (Courtois, 1999; Herman,
1992; van der Kolk et al., 1996).
The model for posttrauma treatment is also sequenced and begins
by focusing on the clients' personal safety and the stabilization
of personal functioning and outstanding life stresses and difficulties
(including dependency); developing the therapeutic relationship
is also addressed. In the first phase of treatment, clients
are encouraged to defer attention to the traumatic material in
favor of personal safety and stabilization. If clients are actively
suffering from posttraumatic symptoms (as well as other symptoms
such as depression and anxiety), these are treated first with
cognitive-behavioral strategies aimed at increasing self-management
and with psychotropic medication as needed. Clients are also
taught skills for identifying and expressing feelings and for
modulating and coping with strong feelings. The traumatic event(s)
and reactions are addressed only as they support clients' stabilization
and from an educational perspective. Clients are given definitions
for various terms (such as trauma and child abuse and neglect)
and are taught about the human response to trauma to normalize
posttraumatic reactions.
The second phase of treatment incorporates much more direct
attention to trauma and its effects. Clients are taught to address
the trauma without the use of negative coping methods (including
substances and processes such as dissociation) but must also
learn that exposure must be carefully monitored so that they
are not overwhelmed and retraumatized. Facing traumatic material
is usually the most difficult and painful part of the treatment,
and clients often relapse to old coping methods. For this reason,
they are actively engaged in relapse planning, including the
identification of triggers and strategies to use when they feel
overwhelmed. As the trauma is processed and resolved, clients
gradually move into the work of the third phase, which focuses
on life choices and on a life less encumbered by the effects
of trauma. This phase may last long after the client completes
treatment.
The counselor must be aware of personal and interpersonal
developmental deficits (see "Challenges to Accurate Screening
and Assessment" in Chapter 2) and must
work to remediate these issues through skill development and
through the counseling relationship.
Clients with a history of child abuse or neglect typically
have feelings of abandonment and betrayal that often become funneled
into rage. In addition, substance use that began at an early
age--between 8 and 18 years, when children should be learning
to develop intimacy and deal with their feelings--can result
in arrested emotional development and an inability to deal with
strong emotions while abstinent. Assisting these clients to
develop life management skills begins with helping them to identify
and understand the intensities of their feelings. It is the
unfortunate legacy of childhood abuse that victims must learn
to repress their emotions to survive. Victims tend to become
vigilant to the emotional states of others at the expense of
being aware of their own. In cases of repeated abuse, the victims
become constantly alert to the abuser's every move and nuance
in order to avoid sparking another abusive incident. That ability,
which served them well in childhood, has now been carried over
into adulthood and interferes with the ability to function with
a full range of feelings.
For victims of abuse, problems in forming attachments are
often paramount. The abuse has led to feelings of distrust,
betrayal, and abandonment and has caused a disconnection from
other human beings. Substance abuse only compounds this rift
by creating a false sense of belonging. The process of reattaching--or
attaching for the first time--to other individuals, to a community,
or to a spiritual power may take a long time, but it does have
great therapeutic value. This may involve an activity--such
as taking a class in writing or painting, working with animals,
or joining a 12-Step group or a church--that fosters feelings
of belonging. Daily affirmations--the reflection on positive
statements about oneself--may help foster spiritual growth.
For clients, spirituality may be in the form of an organized
religion or activity in which participation makes them whole,
centered, and connected to some superior or overarching force
(Whitfield, 1984).
Clients who grew up in an abusive household have learned survival
skills that allowed them to function in an often hostile and
unpredictable environment, one in which they needed to be hypersensitive
to others' moods and behaviors. Fears of intimacy are likely
to hinder them, and the counselor must respect these clients'
boundaries and limitations. Clients' fears of intimacy will
often manifest themselves in concern about losing control or
being abandoned or attacked (Sheehan, 1994).
Counselors may need to explain to clients how the problems
in their past can affect their relationships in the present and
how proper skills training can help them to overcome these deficits.
Counselors should reassure clients that these deficits are understandable
in light of their history and should be prepared to help them
develop needed interpersonal skills.
Helping clients develop interpersonal skills involves enabling
them to interact empathetically with others, to understand and
be understood, to be able to ask for what they need, to draw
personal boundaries by saying no, and to cope with interpersonal
conflict (Whitfield, 1993). Other skills
highly useful for this population include anger management, learning
how to recognize unhealthy relationships, assertiveness training,
and conflict resolution. The development of such skills allows
clients to establish and maintain interpersonal relationships
while keeping their self-respect.
Because of the central role of interpersonal relationships
in women's development, women with substance abuse disorders
and histories of child abuse are particularly vulnerable to interpersonal
stress--and responsive to interpersonally focused interventions.
Because the support networks of these women are typically impoverished,
interventions that provide an immediate support network as well
as foster improvement in interpersonal skills are essential first
steps in shoring up the women's social networks and bonds (Luthar and Suchman, 1999; Luthar and Suchman,
in press).
One of the most important roles of the counselor is to model
behaviors in healthy relationships. Many abuse survivors never
learned this in childhood and have to learn the most basic skills.
The counselor should make it a point to show up on time and
have expectations for clients to do so as well; he should also
always behave in a warm and respectful manner. By simply being
there, the counselor models key aspects of a healthy relationship:
consistency, respect, empathetic listening, trust, and setting
clear boundaries.
Group therapy can be a good setting for interpersonal skills
training, but because of the highly volatile and sensitive nature
of childhood abuse and neglect, group therapy may not be appropriate
for many clients dealing with these issues (see the "Group Therapy"
section later in this chapter).
Seminal writings about the therapist's contribution to the
therapeutic interaction (Rogers, 1959;
Traux and Carkhuff, 1967) suggest that
certain characteristics are essential for effective treatment
across therapeutic modalities: (1) unconditional positive regard
or nonpossessive warmth, (2) a nonjudgmental attitude or accurate
empathy, and (3) sincerity. Although many would argue that
these are not sufficient for positive outcomes, there is evidence
that these characteristics are important to establishing a working
alliance with the client. For example, research has shown that
an empathic therapist style is associated with more positive
long-term outcomes (Miller and Sovereign, 1989; Miller et al., 1980).
For effective treatment, clients must be motivated for change.
A counselor may need to address motivation before change can
occur. For the counselor, the pace of some clients may seem
so slow that it appears the clients are avoiding the issue.
Nevertheless, the counselor must respect the clients' boundaries
regarding how much and when to talk about abuse or neglect.
To force the issue or to confront clients about abuse would be
to reenact the violating role of the perpetrator. In dealing
with clients with histories of child abuse and neglect, the counselor
must strike a delicate balance between allowing clients to talk
about the abuse when they are ready and not appearing to maintain
the conspiracy of silence that so often surrounds issues of child
abuse.
The counselor also must be prepared for the possibility that
clients may disclose their childhood abuse or neglect without
being asked about it. Disclosure of past abuse or neglect sometimes
happens spontaneously in counseling sessions, without any intentional
elicitation from the counselor or preplanning on the part of
clients. In some cases, clients believe that the sooner they
address the abuse, the sooner they can resolve it. Exposure
to the issue in the media may have led others to believe that
this is typical, that is, "what they are supposed to do." Still
others feel a sense of urgency because they know they are allowed
only a limited period of treatment. They may attempt to pressure
treatment providers into addressing abuse issues prematurely--before
they have adequate coping skills to manage the potential effects
of such exploration. However, counselors must maintain appropriate
pacing and teach clients to develop skills in self-soothing techniques
so they can manage uncomfortable or volatile feelings.
When working with adult survivors of childhood abuse, the
counselor can help clients situate the abuse in the past, where
it belongs, while keeping the memory of it available to work
with in therapy. Emphasizing a distinction between the emotions
of the client as child victim and the choices available to the
adult client can help this process. Recognizing this separation,
clients can learn to tolerate memories of the abuse while accepting
that at least some of its sequelae will probably remain.
Regardless of how or when clients talk about their abuse histories,
the counselor must handle such disclosures with tact and sensitivity.
Children who have been abused, especially at a young age by
parents or other caretakers, will usually find it difficult to
trust adults. When children's first and most fundamental relationship--that
between themselves and one or both parents--has been betrayed
by physical, emotional, or sexual abuse, they are likely to grow
up feeling mistrustful of others and hypervigilant about the
possibility of repeated betrayals. This vigilance is, in many
ways, a resilient strength for children, who lack many of the
protective resources of adults. As adults, however, it often
stands in the way of forming intimate and trusting relationships.
The counselor must take care not to tear down this defense prematurely,
because to do so may result in discrediting or invalidating the
experience of the abuse and in some cases may be perceived as
abusive in itself. Patience and consistency help to reassure
clients of the counselor's trustworthiness. Counselors should
not assume that they have the clients' confidence simply because
a disclosure has been made; with victims of childhood abuse,
trust is often gained in small increments over time.
When the treatment does focus on issues of past abuse, the
Consensus Panel recommends that the counselor support clients
for what they can recall while reassuring them that it is quite
normal to have uncertainties or not to remember all of what happened
in the past. More important than the accuracy of the memory
is the emotional reaction to, and consequences of, the experience;
memories over time may be distorted, especially when remembered
through the eyes of a child, but the feelings they engender are
the most significant aspect of the experience. This last point
is especially important because many survivors fear that if they
disclose their histories, whomever they tell will deny that it
happened. Even if the counselor finds clients' accounts difficult
to believe, he can look for and respond to the emotional truth
of it.
Moreover, the counselor should remember that until some degree
of abstinence is achieved, clients' perceptions of reality are
likely to be limited and their judgment poor. When clients disclose
histories of past abuse before abstinence has been achieved,
the counselor should note the information on childhood abuse
and neglect, realizing that it will be important to explore this
matter more thoroughly when clients have achieved a period of
abstinence. When the topic is revisited later, the counselor
should explain what parts of the story are the same and what
parts differ, because this information may be therapeutically
important. It is not unusual for trauma survivors to remember
more with the retelling of their stories; however, the counselor
should make note of major inconsistencies in order to discuss
them with clients over the course of treatment. For example,
the abuse may have been perpetrated by someone other than the
person whom the client first remembered. Information such as
this can have an extremely important bearing on family counseling,
as well as other aspects of treatment.
Counseling techniques for treating substance abuse in clients
with a history of child abuse or neglect include interviewing
from a stance of supportive neutrality. By asking, for example,
what clients believe was both good and bad about the substance
abuse, the counselor explores clients' perspectives and elicits
rather than conveys information. The counselor's goal should
be to motivate clients to explore their own issues and determine
for themselves how the history of abuse relates to their substance
abuse. Clients' motivations--for dealing with either abuse or
substance abuse--will waver, but that is part of the process.
(For more information on motivational techniques, see TIP 35,
Enhancing Motivation for Change in Substance Abuse Treatment[CSAT, 1999c].)
Although group treatment, including 12-Step programs and group
therapy, is generally the treatment of choice for individuals
who abuse substances (Barker and Whitfield,
1991; Washton, 1997), some individuals
with childhood abuse issues may not do well in group settings.
They may either find themselves unable to function or else try
to undermine the group process to protect themselves from painful
issues they would rather not face. This kind of behavior may
point to hidden issues that the counselor should explore further.
If childhood abuse issues surface during a group session (as
they often do), they should not be ignored, nor should clients
be discouraged from talking about such issues. However, trauma
itself should not be the focus of treatment for a substance abuse
disorder.
The length, intensity, and type of treatment may need to be
altered for clients if childhood abuse or neglect issues surface
during treatment. If possible, clients with these issues should
be given the chance to participate in groups that focus on the
specific issue of adult survivors. Trauma-related groups are
not generally recommended during the early stages of treatment
for a substance abuse disorder, when clients are still trying
to achieve abstinence; however, groups that are designed to teach
and educate clients about trauma and substance abuse can, at
times, be quite helpful. (Exceptions can be made, however, for
clients who continue to relapse during this early stage of treatment.)
Survivors of childhood abuse should participate in a trauma-focused
group only after clients' "safety and self-care are securely
established, their symptoms are under reasonable control, their
social supports are reliable, and their life circumstances permit
engagement in a demanding endeavor" (Herman,
1992, p. 224).
In some cases, the first clue about the possibility of childhood
abuse may be that a client is constantly undermining the group
process, or the client may simply withdraw, becoming silent or
dropping out of the group. Group therapy can be done effectively
with this population, but counselors should keep in mind the
population and the issues being dealt with and adjust goals accordingly.
The group process can be an excellent way to help these individuals
begin to address their attachment issues and--in a safe, controlled
environment--practice disclosure and providing support to others.
Adult survivors who are severely dissociative may have a hard
time in any group setting. It is important that these clients
are offered a symptom management program in which they can learn
to use coping mechanisms other than dissociation. Clients with
dissociative disorders may be very suggestible and easily disturbed
by peer discussion of stressful experiences. This is not only
a problem for the survivor in question but can also be disruptive
and distressing to the group.
The appropriateness of group therapy for substance abuse treatment
should be assessed for each client. As a general rule, though,
groups that provide education, support, and counseling about
substance abuse, trauma, and posttraumatic reactions are preferable
in the early stages of treatment to groups that try to provide
more in-depth therapy. For example, intensive group psychotherapy
is generally not beneficial for new clients in the primary stages
of treatment, which should focus on more general substance abuse
issues (Barker and Whitfield, 1991).
Clinical experience indicates that groups structured specifically
for women or men are more beneficial, especially during the early
stages of substance abuse treatment. After clients have become
more stabilized and can better empathize and share with others,
mixed-gender groups may be more appropriate and can offer special
opportunities for individuals to work through their issues differently.
Some clients, however, may never be comfortable in mixed groups,
and this should not necessarily be viewed as a measure of progress.
Gender-specific groups are equally beneficial for abuse survivors
in treatment, particularly if the abuse issues are identified
early.
Research shows that women especially tend to do better in
groups specific to women (Lerner, 1988;
Wald et al., 1995; Wedenoja
and Reed, 1982), although men may benefit from male-only
groups as well (Briere, 1989; Catherall
and Shelton, 1996; Corey and Corey, 1996; Harrison and Morris, 1996; Krugman,
1998). It is also helpful for sexual minorities (e.g., gay,
lesbian, transgendered) to have their own groups when possible.
Women who have been victims of sexual abuse perpetrated by men
may find it more difficult to discuss that abuse with men present.
However, in gender-specific groups women may be more willing
to discuss their abuse than men. All-male groups may need more
assistance from the counselor to begin discussing this topic.
Women and men have different conflicts and issues when dealing
with their abuse experiences, but both might be affected by traditional
societal views of gender roles. The difficulty that many men
face in acknowledging past abuse is sometimes compounded by the
conflict between perceiving themselves as victims and society's
traditional expectations of men as powerful and aggressive.
Male homophobia can also make discussions of sexual abuse, which
often involve same-sex assaults, less likely to occur. Men may
need help to form a view of themselves that neither exacerbates
their feelings of victimization nor imposes unrealistic expectations
of unwavering strength. Similarly, traditional societal views
of women reinforce stereotypes of female helplessness. Whatever
the gender stereotype, both men and women can often benefit from
assertiveness training and learning to form healthy self-images
that are not based on notions of fear and powerlessness. Some
men may find it more difficult to work on these issues, or may
be in denial, because of the social stigma around male weakness.
Whether treating individuals with abuse histories in mixed
or gender-specific groups, it is important for counselors to
avoid having preconceived notions about abusive events. Females
may be more often the victims of sexual molestation by males,
but sexual abuse is also perpetrated on males by both sexes and
on females by other females. Given common expectations, it is
especially important not to belittle men's experiences because
many men have difficulty expressing uncomfortable emotions associated
with abuse. For example, men who were sexually abused as children
by females often have significant issues of shame surrounding
the abuse (Krugman, 1998). In other cases,
the enormous social taboo surrounding the sexual abuse of a son
by his father can lead the survivor to feel that he somehow invited
the abuse or to question his sexual orientation. Another common
scenario is that of men who had distant and unavailable fathers
and were abused at young ages (such as 12 or 13) by older men
who sensed their neediness for a male connection during puberty
(Catherall and Shelton, 1996; Harrison
and Morris, 1996; Krugman, 1998).
The unfortunate truth of child abuse is that any scenario
is possible. Both men and women are equally susceptible to the
emotional damage that results from the profound betrayal of their
trust in the adults who were supposed to take care of them.
It is incumbent upon all treatment professionals, therefore,
to bring to their work with these individuals sufficient knowledge,
sensitivity, and understanding of the unique issues surrounding
childhood abuse and neglect.
Many alcohol and drug counselors are committed to the 12-Step
model; however, that model can be problematic for clients with
childhood abuse and neglect. Many survivors believe they do
not have any control or power. Therefore, a 12-Step approach
that asks them to accept their powerlessness might be more harmful
than beneficial. The importance given to "surrender to a higher
power" can also terrify or anger abuse survivors. They have
had personal and very dangerous experiences with submission to
human power and have often lost hope in higher spiritual powers
that did not protect them in the past. Counselors must be sensitive
to and respectful of survivors' needs to avoid this terminology.
Twelve-Step organizations that work with this population (e.g.,
Survivors of Incest Anonymous) have reworded this step to make
it less problematic for this population. In general, self-help
groups can be tremendous sources of help for clients with all
types of associated problems.
When adult survivors of child abuse enter treatment, clients'
families may have a significant effect on the way in which treatment
progresses. Every family has a unique style or unspoken set
of rules that is used to maintain equilibrium in the family system
(Satir and Baldwin, 1983). That equilibrium
is thrown off balance by changes occurring with any family member.
If one part of the family value or belief system changes, all
parts of the system change--which may be threatening to some
family members. When an outsider, such as the alcohol and drug
counselor, tries to work with the problems presented by the client,
the tendency in some families is to close ranks and come together
to maintain a sense of equilibrium. The dynamics within abusive
families may remain secretive, coercive, and manipulative, even
if the actual abuse is no longer happening. Often the resistance
of families is a way to protect and avoid disclosure, and abusers
may still hold a strongly controlling position, even over their
young-adult and adult children.
When family members oppose change, it often becomes evident
during the course of treatment. The family may minimize the
importance of the problem and not support the client's counseling.
This is particularly true in families where substance abuse
and child abuse are present; the family may be isolated from
larger society and be fearful or angry about the counselor's
interventions. In some cases, abusive situations may be currently
taking place in the family. It is important to note that other
family members may not know or want to know about the abuse of
another member, whether ongoing or in the past. The counselor
should understand that the resistance being encountered is taking
place to preserve the family in the only way available to it.
Of course, many families welcome change and want their family
member to be abstinent; too often the family may be viewed as
a potential problem when in fact it could be a great asset.
The counselor should talk frankly with the family about the fact
that change will be uncomfortable and stressful.
When family therapy is agreed on as a useful component of
substance abuse treatment, it should only be conducted by a licensed
mental health professional with specific training in the area
of child abuse and neglect.
When clients' families become involved in treatment, a decision
must be made whether and to what degree the subject of abuse
will be discussed. This decision is best made between the client
and the counselor outside of family sessions (deciding whether
to disclose to anyone outside the therapy relationship is strictly
up to the survivor; mandated reporting laws, discussed in Chapter 6, would be an exception to this).
In dealing with clients' current nuclear families, the counselor
should explore with clients the possibility of discussing the
past abuse within the context of how it affects the clients'
substance abuse and current functioning within the family. In
any first-time disclosure of abuse, the counselor must take care
not to pressure clients to talk about the abuse with their families
before they are ready. For the counselor to do so would be to
reenact the role of the perpetrator.
Enlisting family members to support a client's treatment may
have a positive impact on recovery. In some cases (e.g., when
the perpetrator of the abuse is still present in the family),
a team review should take place to decide whether to include
the family. The team must take into account the client's comfort
level and readiness for involving family, as well as her progress
thus far in treatment for both substance abuse and mental health
issues and any mandatory reporting guidelines that might apply.
Counselors should be very cautious about discussing child abuse
issues with family members while the client is still in treatment
for substance abuse. Such confrontation may not be considered
therapeutic or essential for every client.
Obviously, it is a delicate matter to discuss past abuse in
the presence of family members who participated in or were present
during it. When such a decision is made, the counselor must
bear in mind that he does not, and should not, have the role
of confronting the perpetrator. The counselor must avoid
taking on the role of rescuer or defender of clients (see Chapter 4). For the counselor to insert
himself into the perpetrator-victim system is to put an end to
his therapeutic effectiveness. Nor is the purpose of enlisting
family in treatment to allow clients to confront the perpetrator.
As in individual sessions with clients alone, the focus must
remain on supporting the client's recovery.
A number of problems are associated with accusing family members
of abuse of their adult children. One risk is that the accusation
will be denied, or the client will be blamed for the abuse, provoking
intense emotions and possible relapse. Another problem is political
and legal; there has been a strong reaction to accusations of
childhood abuse by adults molested as children. Counselors have
been accused and sometimes sued for implanting false memories
as well as subjecting family members to unexpected accusations
when they thought they were going into family therapy in support
of their recovering son, daughter, or sibling. This is an unfortunate
turn of events for counselors who believe clients and see dealing
with these issues as important for recovery. In many cases,
mediation is an effective option, but it is not possible with
some families.
In most cases, open negotiations with an adult client's family
of origin about past abuse should probably not happen until very
late in individual therapy, if ever. (For a child or adolescent
the situation and issues are quite different, of course.) Substance-dependent
clients who have been abused are doubly vulnerable to further
hostility and rejection from their families and may respond with
either massive anxiety or relapse or both. Involving supportive
family members might help with particular issues; for example,
a domestic partner can be included in sessions on sexual or emotional
intimacy problems.
In general, abused substance-abusing clients benefit most
by a strong primary alliance with the therapist and not too much
dilution with other relationships. This undivided support and
allegiance in a relationship is, after all, what was usually
lacking for the clients and what is needed to rebuild the self.
Intensive individual therapy is usually the best approach for
this type of client. The intended benefits of family therapy
are often not worth the potential risks to clients in this unpredictable
and emotionally charged situation. Furthermore, it must be emphasized
that counselors should take a team approach whenever feasible
and not take on more than is appropriate for their level of training,
experience, and abilities.
The determination of whether family therapy is effective and
appropriate for clients with histories of abuse or neglect depends
on a number of factors. Among the most important is whether
the history of abuse is known and acknowledged by the family.
Other important considerations are clients' feelings and preferences
and their current relationships with various members of their
families. In evaluating the need for family therapy, providers
must also consider clients' personal definitions of family, which
may not fit expected norms. Regardless of biological relationships,
the issue at hand is to identify the people who are nonthreatening
and important in clients' daily functioning.
Before involving clients' families in treatment, the counselor
must evaluate clients' tolerance level for the highly charged
emotional material that is likely to ensue from taking this step.
Ultimately, this decision should be made by the entire treatment
team, including a mental health professional. However, family
involvement is often therapeutic for the client and may be a
predictor of successful recovery.
The counselor is in the delicate position of trying to gain
the cooperation of families and engage clients in a way that
does not threaten the family balance. A lack of understanding
of clients' culture and specifically the family norms of that
culture may hinder this process. In some cultures, someone outside
the family may be viewed with distrust and her assistance is
considered as interference. Or, in some cultures, calling the
father by his first name may violate his authority and alienate
him from the treatment process. Being aware of cultural norms
that can influence the situation helps the counselor better understand
clients and create a framework in which effective therapy can
take place.
There is now an influx of immigrant populations to the United
States from all over the world, and many come to this country
because they have been displaced by war or other traumatic events.
It is not possible for a counselor to be aware of all the issues
faced by clients. Therefore, it is helpful for the counselor
to ask clients and their families to teach him what he needs
to know about the values of their culture. Admitting a lack
of knowledge and asking specific questions demonstrate respect
and are ways in which family members can participate in the treatment
process. Families are often willing to discuss these issues,
and the counselor gains the information needed to work with the
client while building trust.
Counselors must be careful not to attempt too much when working
with clients with a history of severe abuse. Although the best
situation is one in which substance abuse and other mental health
issues can be treated together in the same program, programs
do not always have the resources to do so. When an assessment
of symptoms indicates mental health problems that are beyond
the scope of the counselor's ability to treat, a referral is
clearly warranted. Suicidality, self-mutilation, extreme dissociative
reactions, and major depression should be treated by a mental
health professional, although that treatment may be concurrent
with substance abuse treatment. The need for a referral, however,
is not always so clear.
The treatment provider's first goal for clients is generally
to help them stop using substances and maintain abstinence.
Clients may wonder or inquire why they are being asked about
their childhood in a program for substance abuse and dependence.
For the therapeutic process to be effective, both counselors
and clients may need to reach a deeper understanding of how the
past contributes to present problems. Although the counselor
is primarily concerned with substance abuse, she is often in
the crucial position to identify clients' other needs, which
if not addressed might lead to relapse or escalation of substance
use.
The desired outcomes of referral for counseling about childhood
abuse issues include the expectation that the referral is actually
acted on, but referrals can only be made (and followed up on)
with the client's permission. The treatment provider should
follow through on the referral process to ensure that it is completed.
Once a referral has been made, the mental health provider can
help elicit further information about the client's history of
child abuse or neglect. For clients with more severe mental
health problems, the treatment provider's primary concern should
be to ensure clients' safety and help minimize the risk of suicidality
and relapse.
Treatment planning for clients with childhood abuse should
be a dynamic process that can change as new information is uncovered,
taking into account where clients are in the treatment process
when the history of abuse is disclosed. What is known by both
counselor and clients at the beginning of treatment is often
different from what is learned later, as clients' capacity for
coherence and clear thinking improves. Clients newly admitted
to treatment who have not yet achieved abstinence are not likely
to think clearly, to process or synthesize information, or to
engage in meaningful self-reflection. Confronting abuse issues
at such an early point in treatment may lead to escalation of
substance use.
The counselor should prepare clients for mental health treatment
by helping them realize (1) that their history of child abuse
or neglect may have contributed to some of their errors in thinking
and decisionmaking, (2) that they may have medicated themselves
with substances in order not to deal with their feelings, (3)
that they are not alone and resources are available to help them,
and (4) they can learn better ways to cope and live a happier
life. Regardless of when abuse issues arise in treatment, the
counselor should gather information from clients to identify
the referral sources that will be most appropriate and helpful.
This information helps treatment staff as well, because past
abuse may influence a person's chances of recovery and progress
through treatment.
Decisions of when and where to refer will vary depending on
the availability of local services. When those services are
limited or nonexistent, treatment providers may have to be creative.
Asking clients about possible sources of support--such as those
they may have turned to in the past when this issue arose--may
turn up resources such as clergy, teachers, or others in the
community.
Case management and coordination of services are key to the
provision of integrated or concurrent treatment and of appropriate
referrals, especially in the case of referrals for childhood
abuse and neglect issues. Once made, such referrals do not mark
the end of substance abuse treatment. On the contrary, treatment
for substance abuse disorders remains integral in the case management
process.
Linkages between treatment providers and mental health agencies
are crucial if the two programs are to understand each other's
activities. In the interest of the clients, a case summary should
be developed that lists the key issues that need to be addressed
in other settings. (See Appendix B
for information on getting the client's consent before making
referrals or sharing information.) This not only helps clients
but also enhances professional relationships between parties.
Ideally, a case manager will coordinate all these services,
but often the counselor serves as the coordinator. For more
information on the importance of case management services in
substance abuse treatment, see TIP 27, Comprehensive Case
Management for Substance Abuse Treatment (CSAT,
1998a).
The reality of third-party payor systems is that substance
abuse treatment is limited to a finite number of visits. Documentation
of child abuse or neglect issues and their effect on the treatment
process helps to delineate specific treatment intervention needs
and allows for more effective treatment planning. Demonstrating
the existence of childhood abuse or neglect and its impact on
current dysfunctional behaviors early in treatment supports the
complexity of the diagnosis and treatment planning process, thus
helping to substantiate the need for greater support to third
party payors. Counselors will often need to substantiate the
complexity of a case so that they can begin to formulate a treatment
plan. It helps to describe specific behaviors rather than using
labels such as "substance abuse" or "childhood abuse and neglect,"
which will allow for behaviorally based interventions. A mental
health assessment can provide a diagnosis that will be more acceptable
for third-party payors.
Working with at-risk clients in today's litigious climate
requires that counselors adhere closely to accepted standards
and ethics of practice as well as the legal requirements of their
position. Working within a multidisciplinary team with adequate
supervision ensures that the counselor maintains such standards
of care. Team members or colleagues in other agencies can be
consulted about treatment issues as well as legal matters concerning
reporting requirements and confidentiality.
Clients' treatment records are important documents. They
provide historical overviews of each client's current status,
past experiences, treatment goals, and subsequent progress. Counselors
need to record this information in an organized, respectful,
and sensitive manner, with the knowledge that others may have
access to clients' records. It is best to find a balance in
the level of detail recorded. Counselors should make it a practice
to document only the factual, observable behavior of clients,
and to record statements made by clients and not make judgmental
statements about them. It is important to build an efficient
means of recordkeeping that follows both Federal and State guidelines.
Instances of abuse and neglect that have been revealed must
be recorded. To protect the provider, the record should state
that the client reported abuse, rather than that the client was
abused. When counselors do not record the information they are
given, they lose the opportunity of transmitting needed information
to future counselors. The message to the client must be that
the information is important and needs to be recorded. If not
recorded, the counselor is furthering a message of shame and
secrecy. Often the information on past trauma or abuse is essential
for developing a treatment plan and thus can help strengthen
subsequent treatment. The case summary should document such
things as clients' status at intake, the diagnosis, course of
treatment (including any prescribed medications), status at discharge,
the goals met while in treatment, the reason for discharge, and
any referrals made. Records should also indicate the extent
to which the original goals of the treatment plan were reached.
Sufficient notes should be kept for this purpose because the
outcome of treatment has important implications for accreditation
and funding. Of course, sharing information in the record is
bound by the rules of confidentiality (see Chapter
6 and Appendix B.)
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