www.psychceu.com: A Research Based Guide to Drug and Alcohol Addiction Treatment for Persons With Child Abuse and Neglect Issues

consisting of reading and taking a post-test on
Substance Abuse Treatment for Persons With Child Abuse and Neglect Issues
Treatment Improvement Protocol (TIP) Series 36

National Institute on Drug Abuse
National Institutes of Health
Principles of Drug Addiction Treatment
A research-based guide

Child abuse and neglect pose an increasingly recognized and serious threat to the nation's children. The reported cases
of abused and neglected children have more than doubled from 1.4 million in 1986 to more than 3 million in 1997.
Research suggests that adults with histories of child abuse and neglect are at high risk for developing substance abuse
disorders. Moreover, these childhood abuse and neglect issues may negatively affect clients' chances for recovery
from substance abuse. Compounded with these problems is the increased likelihood of substance−abusing parents
abusing their own children. By most accounts, substance abuse contributes to almost three fourths of the incidents of
child abuse or neglect for children in foster care.

The effects of childhood abuse and neglect perpetrated by family members and the intergenerational transmission of
the cycle of substance abuse and child abuse and neglect are the focus of this TIP.
Throughout this TIP, the term "substance abuse" has been used in a general sense to cover both substance abuse
disorders and substance dependence disorders (as defined by the Diagnostic and Statistical Manual of Mental
Disorders, 4th Edition [DSM-IV] American Psychiatric Association, 1994). Because the term "substance abuse" is
commonly used by substance abuse treatment professionals to describe any excessive use of addictive substances, in
this TIP it will be used to denote both substance dependence and substance abuse disorders. The term relates to the use
of alcohol as well as other substances of abuse. Readers should attend to the context in which the term occurs in order
to determine what possible range of meanings it covers; in most cases, however, the term will refer to all varieties of
substance use disorders as described by DSM-IV.
To avoid both sexism and awkward sentence construction, the TIP alternates between the pronouns "he" and "she" in
generic examples.

Recommendations
The Consensus Panel's recommendations, summarized below, are based on both research and clinical experience.
Those supported by scientific evidence are followed by (1); clinically based recommendations are marked (2).
Citations to the former are referenced in the body of this document, where the guidelines are presented in detail.
The Consensus Panel recommends that, when working with clients with substance abuse problems and histories of
childhood abuse and neglect, counselors adopt a broad approach that considers the meaning of the experience to the
client, not just legal definitions of child abuse and neglect. (1) Counselors must, therefore, understand how clients
interpret their experiences. Not all abuse meets the legal or commonly held criteria for abuse, nor do all clients
perceive as abusive behavior that which might be legally defined as "abuse."

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.
Counselor issues
Counselors who will be screening for and assessing histories of child abuse or neglect should receive specific training
in these areas. (2) Although there are no rigid rules regarding who should conduct screenings, having certain skills
will increase the likelihood that the screening process is conducted appropriately. Staff members should have an
understanding of the types of psychiatric disorders and symptoms that are commonly associated with histories of
childhood abuse and neglect.
Counselors who conduct screenings will be prompting clients to recall painful and traumatic events. The reemergence
of painful memories may cause intense reactions from clients. Treatment staff should be sensitive to this and prepare
for the interview in the following ways:Inform clients that talking about such issues might create discomfort; clients should be given a choice to
disclose such information, being aware of the possible aftermath. (2)
¨
Have proper supervision and support mechanisms in place for clients in case a crisis occurs following
disclosure (e.g., accessibility to mental health practitioners or medical personnel). (2)
¨
Assess the sources of social and emotional support available to clients when they return home. (2) ¨
There are many potential barriers to successful screenings and assessments of childhood trauma. To reduce some of
these barriers, the Consensus Panel recommends the following:
Be sensitive to cultural concerns. (1) ¨
Recognize potential language differences. (2) ¨
Become aware of gender issues. (2) ¨
Be nonjudgmental and sensitive. (1) ¨
If counselors experience intense discomfort and anxiety when conducting screenings and assessments, the Consensus
Panel recommends that they receive guidance and support from a clinical supervisor and consider whether they could
benefit from therapeutic assistance to explore the reasons for their discomfort. (2) A variety of instruments for
screening and assessment are discussed in Chapter 2.

Screening
The Consensus Panel suggests screening for child abuse and neglect histories early in the assessment process to
identify individuals who exhibit signs and symptoms associated with child abuse and neglect (such as posttraumatic
stress disorder [PTSD], major depression, or mood disorders) and to identify those who may benefit from a
comprehensive clinical assessment. (2) Screenings should also be conducted at different times throughout the
treatment process. Repeated screenings help elicit information about these traumatic experiences--especially after
trust has been established in the therapeutic relationship. (2) To conduct a screening effectively, treatment staff should
Learn and understand ways in which childhood abuse and neglect can affect adult feelings and behaviors. (2) ¨
Identify those individuals who appear to exhibit these symptoms. (2) ¨
Identify the trauma-related treatment needs of these clients. (2) ¨
Provide or coordinate appropriate treatment services that will help meet clients' treatment needs. (2) ¨
Screening for childhood abuse or neglect can set in motion a proactive plan with the following benefits:
Stopping the cycle. Although not all adults who were abused or neglected during childhood abuse their own
children, they are at greater risk for doing so. (1)
¨
Decreasing the probability of relapse. Many substance abusers consume substances to self-medicate
posttraumatic stress symptoms related to past physical or sexual abuse or trauma. (1)
¨
Improving a client's overall psychological and interpersonal functioning. Childhood sexual abuse and neglect
may affect the individual's self-concept, sense of self-esteem, and ability to self-actualize. (2)
¨
Improving program outcome. Screening for a history of child abuse or neglect will help a program to
determine the needs of its clients, thus improving treatment outcomes. (2)
¨
Assessments
The primary purpose of an assessment is to confirm or discount a positive screening for childhood abuse or neglect, as
well as to identify clients' needs so that treatment can be tailored to meet them. The more clinical information a
program has about clients' particular treatment needs, the better the program can accommodate them. All clients who
screen positive for a history of childhood abuse or neglect should be offered a comprehensive mental health
assessment. (2) There is no standard trauma-oriented assessment tool, and no single tool can be considered truly
comprehensive. Rather, wisely selected, each of these tools can be a valuable component of a comprehensive
assessment process.
When deciding whether to conduct assessments for a history of child abuse or neglect, the treatment team should
evaluate clients'
Current substance use or quality and length of abstinence ¨
Commitment to the treatment and recovery process ¨
Risk of relapse ¨
The Consensus Panel believes that treatment decisions and activities are best conducted within the context of a
multidisciplinary treatment team, with members having special knowledge in such areas as mental health, child abuse
and neglect, and family counseling. (2) Each member of the treatment team should help decide if and when to conduct
assessments for childhood trauma, and clients should be asked to evaluate their own readiness to confront child abuse
or neglect issues.
Trauma-related assessments are important because they can help the treatment staff understand the types of childhood
traumatic events experienced by clients, their subjective response and perceptions of these events, and common
current symptoms that may result from childhood trauma. Decisions regarding the types of instruments to use should
be influenced by the purpose of the assessment, the setting of the assessment, the population being treated, and the
individual client and the severity of his problems. (2)
Assessing histories of childhood trauma can provoke or exacerbate a psychological emergency that must be addressed;
therefore the Consensus Panel recommends that the treatment team include a licensed mental health professional to
handle medical issues that may arise and to conduct more formal assessments that may be required.
Subjective experience of the events
How clients remember traumatic events can shape their psychological response more than the actual circumstances
can; counselors, therefore, need to obtain subjective information about these events. Such information is necessary in
order to plan appropriate treatment. Information that should be obtained includes:

What the client thought about during the abuse ¨
What the client felt during the abuse ¨
How the client understood, as a child, what was happening to her and what she thinks about it now ¨
How the client thinks and feels about how the abuse has affected his adulthood and substance abuse, and how
he deals with the aftereffects of the abuse now
¨
The feelings most closely associated with the abuse experience ¨
The client's memories of the abuse ¨
The unique aspects of the client's perceptions about the abuse ¨
The client's coping strategies, and their effectiveness for the client ¨
Childhood symptoms and family characteristics
The assessment should inquire about childhood symptoms and family characteristics that are consistent with and
suggest a history of childhood abuse or neglect.
(2) Symptoms to look for include
Depression (including thoughts of death, passive suicidal ideation, and feelings of hopelessness) ¨
Dissociative responses during childhood ¨
Aggressive behavior or other "acting out," including
Early sexual activity or sexualized behavior ¨
¨
Physically abusing or harming pets or other animals ¨
Other destructive behaviors ¨
Poor relationships with one or both parents ¨
Attachment disorder, difficulty trusting others ¨
Excessive passivity ¨
Passive/aggressive behavior ¨
Inappropriate age/sexuality formation ¨
Blacked-out timeframes during childhood ¨
Excessive nightmares, extreme fear of the dark, or requested locks on doors ¨
Family-of-origin characteristics to consider include
Parental substance abuse ¨
Battering within the family ¨
Involvement with CPS agencies or foster care ¨
Placement with foster parents or relatives ¨
Severe discipline during childhood ¨
Traumatic separations and losses ¨

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)

source: Substance Abuse Treatment for Persons With Child Abuse and Neglect Issues
Treatment Improvement Protocol (TIP) Series 36

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What Is a TIP?
Treatment Improvement Protocols (TIPs) are best practice guidelines for the treatment of substance use disorders, provided as a service of the Substance Abuse and Mental Health Services Administration's (SAMHSA) Center for Substance Abuse Treatment (CSAT). CSAT's Office of Evaluation, Scientific Analysis and Synthesis draws on the experience and knowledge of clinical, research, and administrative experts to produce the TIPs, which are distributed to a growing number of facilities and individuals across the country. The audience for the TIPs is expanding beyond public and private treatment facilities for substance use disorders as substance use disorders are increasingly recognized as a major problem.

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