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Treating Trauma Survivors in a Family Mental Health Clinic

Westchester Jewish Community Services’ (WJCS) Treatment Center for Trauma and Abuse has been in the forefront in Westchester County in providing child and adult survivors of child sexual abuse with effective treatment for almost thirty years. The program began in the Hartsdale clinic with just two staff and has expanded to three additional WJCS clinics and fourteen members in Peekskill, Mount Vernon and Yonkers. The program strives to provide the best quality of service by understanding and treating the problems associated with childhood sexual abuse, most recently through a focus on evidence-based practice. This focus on evidence-based practice ensures that there is adequate research demonstrating the effectiveness of particular treatment approaches, so that the services provided are of the highest quality.

In this article, we will outline basic information about the impact of child sexual abuse, and how the resulting problems guide treatment goals. We will discuss training provided for professionals through WJCS’ Educational Institute on two evidence-based practices for treating adult and child victims of child sexual abuse: STAIR/NST: Skills Training in Affective and Interpersonal Regulation/Narrative Storytelling, and Trauma-Focused Cognitive Behavioral Therapy.

A third of the female population in the USA report having had an experience of childhood sexual abuse; one in six men report the same. One in five people, male or female, report physical abuse during childhood (Briere & Elliot, 2003). This means that if you list ten people you know, at work or at home, at least one, probably two, of them are likely to have been abused as a child. This number is even higher in a mental health clinic setting.

Learning during childhood occurs by osmosis; we soak up whatever is around us and make it our own. If you grow up in a household where parents talk about feelings, provide comfort and soothing, and give help when it is needed, you learn how to label your feelings, how to soothe yourself, and how to trust others. Unfortunately, the converse is true as well. If your parents yell at you when you cry, fail to provide basic needs, and abuse you when you need help, you learn to ignore your feelings or let them rage out of control, and to mistrust others. Thus, childhood trauma has a broad impact on adult functioning because it interferes with basic developmental tasks.

Individuals with a history of childhood abuse are at increased risk for repeat victimization, compounding the problems they deal with as adults. They often suffer from post-traumatic stress disorder (PTSD) related to their abuse (Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995), and experience depression at 3 to 5 times the rate of the rest of population (Breslau, Davis, Peterson, & Schultz, 1997; Putnam, 2003). In addition, they are at increased risk of substance abuse (Breslau, Davis, Schultz, 2003). Childhood trauma and its consequences are topics that cannot be ignored.

At Westchester Jewish Community Services, we are striving to raise awareness of the problems of childhood trauma, as well as train our staff in how best to help survivors. Two classes are offered in the Educational Institute on evidence-based treatments for trauma.

The first class is named STAIR/NST: Skills Training in Affective and Interpersonal Regulation/Narrative Storytelling. The course follows the treatment manual Treating Survivors of Childhood Abuse: Psychotherapy for the Interrupted Life by Cloitre, Cohen, and Koenen. The approach of this treatment is two-fold. First, clients are taught the skills they could not learn in childhood. This includes affect labeling and regulation, distress tolerance, and interpersonal schema therapy. Assertiveness and flexibility in interpersonal relationships are both addressed. The approach is cognitive-behavioral, with a focus on the impact the trauma has had on the developmental acquisition of skills.

The second part of treatment is the Narrative Story Telling, or NST. After the client has learned skills for coping with what can be overwhelming feelings, the trauma memories are directly addressed with NST. It is based on Edna Foa’s exposure therapy treatment for PTSD, with modifications to address the unique qualities of childhood trauma memories. PTSD is an anxiety disorder, and, as with any anxiety disorder, the feared stimulus needs to be confronted repeatedly until the anxiety is extinguished through familiarity. This process is called habituation. An example of simple exposure therapy would be a fear of dogs that is eliminated through spending time with puppies, and then with bigger dogs. In PTSD, the feared stimuli are the memories of abuse, and clients go to great lengths to try to avoid them. Unfortunately, avoidance does not make the memories go away and can cause significant functional disturbance. Thus, the memories must be spoken about until habituation occurs. The act of remembering and speaking about the memories is referred to as imaginal exposure.

The fear of abuse memories, however, is not quite as simple as our dog phobia example. Trauma is taboo, rarely discussed, and as a result its meaning is not processed. The client’s childhood is like a puzzle that has not been put together, and she is often left with beliefs about her history that have not been updated; her life narrative is fragmented. In NST, the client not only goes through imaginal exposure to habituate to her memories, she also applies schema therapy to her memories with the help of her therapist. She works on understanding her history, and putting it into the context of an ongoing, hopeful, future-oriented life.

The second evidence-based trauma treatment taught at WJCS is focused on child treatment. It is named Trauma Focused Cognitive Behavioral Therapy and is the current state-of-the-art treatment for child sexual abuse victims based on work by Judith Cohen, Anthony Mannarino, and Esther Deblinger.

This treatment approach incorporates work with the child and the parent(s), both separately and together. Psychoeducation is provided for both the child and parent(s) to help them understand that the trauma symptoms and reactions they are experiencing are normal. The child is taught coping skills for managing stress, including how to identify different emotions, how to manage intense and negative emotions, and how to “talk back” to negative thoughts. Parents are considered an important part of the therapy team, and so they also meet with the therapist to learn the same coping skills to support the use of these skills outside of the therapy hour. Parent skill building helps guide effective behavior management in the home.

Once these coping skills have been mastered, the child works on a trauma narrative. The narrative is later shared with the parents so that the parents can demonstrate that they can tolerate and support their child in telling their story. Working on and telling the trauma narrative helps the child stop avoiding memories and reminders as well as placing the trauma in the context of something that happened in the past. This treatment has been shown to be most effective in reducing Post Traumatic Stress Disorder symptoms in children and is quite effective in allowing children to heal from the trauma of sexual abuse.

WJCS is very proud of the work that we do to help adult and child sexual abuse victims. We welcome our colleagues around the New York State area to take part in the Educational Institute classes and encourage the use of evidence-based treatment in all treatment centers.

Tamar Gordon, PhD, is Clinic Supervisor at Central Yonkers Mental Health Clinic, WJCS, and Liane Nelson, PhD, is Director of the Treatment Center for Trauma and Abuse at WJCS.

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