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Center for Substance Abuse Treatment. Substance Abuse Treatment for Persons with Child Abuse and Neglect Issues. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2000. (Treatment Improvement Protocol (TIP) Series, No. 36.)

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Substance Abuse Treatment for Persons with Child Abuse and Neglect Issues.

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Chapter 3—Comprehensive Treatment for Adult Survivors of Child Abuse and Neglect

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.

Treatment Issues

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.

Issues Surrounding Disclosure

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 Use of Medications During Treatment

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.

Sequential, Integrated, and Concurrent Treatment Approaches

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.

Timing of Therapeutic Interventions

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.

Interpersonal Issues

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).

Treatment Techniques

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.

Working From a Position of Supportive Neutrality

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].)

Group Therapy

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).

Gender-specific groups for survivors of sexual abuse

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.

Self-help groups

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.

Involvement of the Family In Treatment

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.

Confronting the history of abuse

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.

Deciding whether to involve the family

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.

Respect for Cultural Norms

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.

The Importance of Referrals

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.

Mental Health Treatment Services

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 Service Coordination

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.

Recordkeeping

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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