Screening and Assessment

Without proper screening and assessment, treatment providers may wrongly attribute symptoms of childhood trauma-related disorders to consequences of current substance abuse. Comprehensive screening for root causes of clients' presenting symptoms may greatly increase the effectiveness of treatment. However, counselors face many challenges when screening for and assessing childhood abuse or neglect. Many abuse survivors are ashamed of having been victims of childhood physical, emotional, or sexual abuse and may believe that the abuse was self-induced. Screening and assessment, therefore, should be designed to reduce the threat of humiliation and blame and should be done in a safe, nonthreatening environment. (2)

While conducting screenings and assessments, counselors should be mindful that adult survivors of childhood trauma commonly suppress memories of certain traumatic events or minimize their symptoms, either intentionally or unintentionally. Moreover, issues of confidentiality, mandated reporting, and trust may influence the responses to interviews and questionnaires by making some clients less inclined to reveal personal histories of abuse or neglect. Given the variable reliability of clients' responses, counselors should neither overemphasize nor overvalue the role of standardized instruments.

Treatment Planning

A very important factor in predicting treatment success is the number of services clients receive (e.g., case management, parenting education, counseling for PTSD and childhood abuse). (1) Clients receiving more specialized services, often concurrently with substance abuse treatment, are more likely to stay in recovery. (1) Treatment planning for clients with childhood abuse histories should be a dynamic process that can change as new information is uncovered, taking into account where a client is in the treatment process (e.g., confronting abuse issues too early in treatment can lead to relapse). (2)

However, it is also important for counselors to remember that until some degree of sobriety is achieved, a client's sense of reality is likely to be distorted and her judgment poor. When disclosures of past abuse take place before a client has achieved sobriety, information on childhood abuse and neglect should be heeded, but full exploration of the issue should be postponed until later. (2) Listed below are general recommendations and guidelines counselors should be aware of when planning a client's treatment.

• Counselors should exhibit unconditional positive regard, a nonjudgmental attitude, and sincerity--therapist characteristics that are essential for effective treatment, regardless of therapeutic modality. (1)
• Providers must be sensitive to their clients' cultural issues and how they interact with clients' child abuse or neglect history. The Consensus Panel strongly urges alcohol and drug counselors to be aware of how clients' backgrounds may affect treatment. (2)
• Sympathetic listening can be an important first step in helping a formerly abused client begin the healing process. (2)
• In the initial crisis that often follows a disclosure, the counselor's most important task may be affect management, such as keeping the client calmer by using relaxation techniques. (2)
• Clients who suffered severe childhood abuse may need to be reassured that they are in a safe environment and will not be abused in the present. They may also have to be taught techniques to stay focused in the present. (2)
• Some clients may require medical supervision in inpatient or intensive outpatient programs (at least during the early stages of abstinence) in order to deal with their feelings of rage, anxiety, depression, or suicidality. (2)
• Clients with past trauma should be reassured in treatment that they have the capacity to deal with traumatic memories or related destructive behaviors stemming from childhood abuse. (2)
• Counselors must carefully pace the client's treatment by monitoring anxiety and depression levels and by taking other cues directly from the client. (2)
• Counselors need to isolate the symptoms of substance abuse disorders caused by trauma due to childhood abuse. (2)
• Counselors should search for and apply any available leverage to help clients endure 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 create a new life. (2)
• For clients entering substance abuse treatment, the mere act of completing a questionnaire acknowledging a history of abuse can be tremendously healing and can lead to change, even without the intervention of a counselor. For other clients, however, actively confronting the fact of childhood abuse may be highly disturbing, and counselors must be prepared to respond supportively. (2)
• In acknowledging the client's history of childhood abuse and neglect, the counselor must validate the client's experience by recognizing the issue, refocusing the treatment, and addressing the issue. (2)
• The counselor can help the client develop interpersonal skills through modeling behavior, by empathizing and respecting the client, and by setting boundaries. (2)
• For victims of abuse, the process of reattaching--or attaching for the first time--to other individuals, to a community, or to a spiritual power has tremendous therapeutic value. (2)
• Linkages between substance abuse treatment and mental health agencies are important if the two programs are to understand each other's activities. In the interest of the client, a case summary should be developed that includes the key issues that should be addressed in the next program. (2)
• When symptoms indicate mental health problems that are beyond the scope of the counselor's ability to treat, a referral is clearly warranted. Suicidal thoughts, attempts at 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. (2)
• Counselors should prepare clients for mental health treatment by helping them realize

  • That their history of childhood abuse or neglect has contributed to some of their errors in thinking, behavior, and decisionmaking
  • That they self-medicated with substances in order to avoid dealing with emotions
  • That they are not alone and that there are resources to help (2)
• Working with at-risk clients in today's litigious climate requires counselors to adhere closely to the accepted standards and ethics of practice as well as the legal requirements of their position. Creating a multidisciplinary team and using proper supervision will help ensure that the counselor maintains such standards. (2)
• Substance abuse counselors always must evaluate the appropriateness of including childhood abuse and neglect survivors in group therapy for other clients in substance abuse treatment. Abuse survivors may not be able to handle the group process until they are able to deal effectively with their attachment issues. (2)
• 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 or perpetrators. (2)

Therapeutic Issues for Counselors

It is inevitable that the counselor will react to the client in ways that are not completely objective. Working with this population may evoke powerful feelings in the counselor. It is important that counselors be aware of and manage their own countertransference reactions and seek supervision as necessary. The Consensus Panel offers the following suggestions to help counselors deal with personal issues when working with clients with childhood abuse and neglect histories.

• In order to teach and model appropriate and healthy interactions, counselors should establish and maintain clear and consistent boundaries with their clients. Adult survivors of child abuse or neglect often need a great deal of affection and approval, and counselors must make clear to the client that they are not responsible for directly meeting all those needs. (2)
• Counselors should focus on empowering the client, recognizing that getting overinvolved will rob clients of the opportunity to draw on their own inner resources. (2)
• Clients' previous experiences may cause them to be mistrustful and suspicious of others, including the counselor. To facilitate the development of a trusting relationship, the counselor should not personalize negative responses but be open, consistent, and nonjudgmental whenever interacting with the client. (2)
• The level of violence and cruelty in disclosures about childhood victimization and exploitation may be very disturbing to counselors. When counselors find themselves manifesting symptoms of anxiety or depression, they should seek direction and support through supervision or peer support. (2)
• Counselors must recognize their personal and professional limitations and not attempt to work with abused clients if they lack the clinical expertise or are not able to manage their own countertransference reactions. (2)
• Burnout, or secondary trauma responses, affects many counselors and can shorten their effective professional life. If counselors meet with a large number of clients (many with trauma histories), do not get adequate support or supervision, do not closely monitor their reactions to clients, and do not maintain healthy personal lifestyles, counseling work of this sort may put them at personal risk. To minimize the likelihood of burnout, counselors should not work in isolation and should seek to treat a caseload of individuals with a variety of problems, not only those who have experienced childhood trauma. (1)
• Alcohol and drug counselors are often subject to great stress. They can be expected to function well and provide effective treatment only if their agency gives them the appropriate support. The agency's leadership should strive to impart a sense of vision to staff members that communicates how important their work is as part of the larger effort to break the cycle of abuse and neglect and its impact on society. (2)

Breaking the Cycle

While many adults with substance abuse disorders do not abuse their own children, they are at increased risk of doing so. When children who are victims of maltreatment become adults, they often lack mature characteristics: the ability to trust, to make healthy partner choices, to manage stress constructively, and to nurture themselves and others. Adults with child abuse histories are then more likely than the general population to develop substance abuse disorders. This intergenerational cycle of substance abuse and child abuse and neglect reflects both the direct and indirect relationship between parental substance abuse and family dynamics, child and adult maltreatment, and second-generation substance abuse. Unless effective intervention occurs, there is an increased likelihood that these patterns will be repeated in future generations. The following list offers recommendations to address this cycle.

• Interventions aimed at breaking the cycle of substance abuse, child neglect, and maltreatment are more successful when they are family centered. (1)
• Counselors can elicit information on a client's childhood experience, which can be useful in predicting the nature of current family relationships. (2)
• Just as counselors can expect that substance-abusing parents often will deny their drug use, they can also expect parents to deny neglecting or abusing their children. Counselors should help parents understand that their parenting behaviors may not be appropriate and that these behaviors can negatively influence their children's future development, especially their ability to trust others and to develop self-esteem and pride. (1)
• Counselors should remember to articulate the positive aspects of clients' lives. (1) Focusing only on the negative or risk factors results in shame and a sense of futility and is counterproductive. Increasing clients' self-esteem and self-efficacy (their effectiveness and ability to take responsibility) is a primary step to acceptance of the child-rearing role.

In addition, it is critical that counselors be able to distinguish between actual cases of child abuse and neglect and situations that arise due to cultural differences, poverty, and lack of education. Providers who work with clients from different cultures should try to develop an understanding of that culture's norms concerning child rearing and discipline.

Legal Issues

Because many parents who abuse substances also neglect or abuse their children, it is common for clients in substance abuse treatment to have some involvement with the CPS system. Some substance-abusing parents will be drawn into the CPS system during treatment; others will be compelled into substance abuse treatment by a CPS agency. In either case, it is critical that treatment providers become familiar with the laws governing the CPS system, including

• How child abuse and neglect are defined in their State
• Whether, when, and how a counselor must report a parent or other primary caretaker--or a parent who was maltreated in childhood--to a CPS agency or police
• What happens after a report is made
• How State-mandated family preservation services operate

Although inappropriate child-rearing practices should be addressed in treatment, they may not, in and of themselves, constitute grounds for an abuse or neglect report. However, if counselors have a reasonable suspicion or firm belief that abuse or neglect has occurred, they are required to make a report. (2) It is important for counselors to bear in mind that a parent who abuses substances is not able to adequately supervise a child and, unless other adults are known to be caring for the child, the counselor should alert the CPS agency regarding potential neglect. It will then be the CPS agency's responsibility to decide whether or not to investigate the matter. (2)

Clients should be informed about the mandatory reporting laws at the time of admission and provided with written documentation regarding both the Federal regulations regarding confidentiality and the counselors' duty to report suspected abuse or neglect. The Consensus Panel recommends that the client be required to acknowledge receipt of such notice in writing. (1)

Counselors are usually not under any obligation to report childhood abuse experienced by an adult client many years ago. However, if the known perpetrator now has custody of--or access to--other children, the program should seek advice about its responsibility to report potential abuse or neglect. (2)

Programs should ask staff members who are mandated reporters to consult a supervisor or team leader before calling a CPS agency to report suspected child abuse or neglect, unless the emergency nature of the situation requires immediate action. Clinical supervisors can help determine whether the staff members are dealing with countertransference issues or inappropriate attachment. Staff members should be guided primarily by a trained understanding of the Federal requirements and the written procedures established by the treatment program. Other staff members can offer support, especially when the decision to report is difficult. (2)

Treatment organizations and agencies should provide orientation for all new staff members to inform them about reporting policies and procedures. It is recommended that these policies include provisions requiring staff members to notify their supervisor or appropriate program personnel whenever they make a report. (2)

It is the decision of the client and his lawyer, not the counselor, to determine whether communication or cooperation with a CPS agency will benefit the client. Therefore, it is essential that the counselor communicate with the client's attorney before taking it upon herself to communicate with a CPS agency, except when there is a legal mandate to report. (2) If a lawyer calls with questions about a client's treatment history or current treatment, the counselor must avoid giving any information (even that the client is indeed in treatment), unless the client has consented in writing to the counselor's communicating with the lawyer. (2)