The WJCS Treatment Center for Trauma and Abuse (TCTA) has been in the forefront in providing mental health services to survivors of childhood sexual abuse, and other forms of trauma, in Westchester County for the past 30 years. Many of the individuals seen through this program have a diagnosis of Post-Traumatic Stress Disorder (PTSD) complicated by other factors. It is important to recognize the evolution in understanding, diagnosing and responding to individuals with histories of trauma, particularly children who have been traumatized in their own home during their formative years. In many ways, the growth and success of the WJCS Treatment Center for Trauma and Abuse parallels the discovery and understanding of childhood sexual abuse in our society, and more specifically in the mental health arena.
In the field of mental health, child sexual abuse was first discussed by Sigmund Freud in the 1880s and 1890s. In the course of conducting psychoanalysis he heard from his adult patients about situations in which there were clear indications of sexual abuse during childhood. In fact, they told him that they had sex with adults when they were children. Initially he believed his patients and connected these experiences with adult psychopathology, in particular, anxiety and neuroses. When he made this information public through his writings, he experienced a professional backlash from colleagues who did not believe that children were sexually abused.
Therefore, he developed a secondary theory that the reported childhood sexual experiences reflected unconscious wishes and desires, and did not necessarily have a basis in fact. This “blaming of the victim” caused a setback in understanding and responding to sexually abused children by the mental health profession (and society as a whole) that lasted a very long time.
Individual contributors sporadically acknowledged that child sexual abuse was a problem, such as in the Kinsey Report of 1948 in which nearly one quarter of the women respondents stated that they had sex with adult men when they were children, or had been approached by an adult male looking for sex. However, this information was largely ignored.
Recognition of the issue of child sexual abuse as a significant problem affecting many children, as well as the recognition of the problem of sexual assault and rape, did not happen until the 1960s and 1970s with the Feminist Movement. By 1982, the problem of childhood sexual abuse had permeated the national psyche, and daycare scandals in California and New York served to establish that the problem was nearby and prevalent.
Understanding that existing clinical resources were inadequate to address the traumatic impact of sexual abuse and violence on child survivors and their families, the Westchester County Department of Community Mental Health issued an RFP to fund the establishment of a child sexual abuse treatment program.
Interested in taking on a new project, WJCS social worker Alan Trager was given the job of developing the newly funded “Victims of Incest Program,” along with another staff person. They attended specialized trainings to get up to speed as quickly as possible. They handled individual treatment with incest survivors, incest perpetrators, and family members; conducted groups; and managed a 24-hour Incest Hotline.
On January 9, 1984, a New York Times reporter attended a WJCS group for adult incest survivors and published an article, on the same day as the airing of the first made-for-TV movie about incest, “Something About Amelia.“ The demand for expert commentary propelled Mr. Trager into the pantheon of child sexual abuse experts and put the Victim of Incest Program solidly on the map in Westchester County. Additionally, the movie spurred an unprecedented number of calls to sexual abuse hotlines, further establishing that this problem was real, sizeable and needed a coordinated response from mental health experts.
Now in its 30th year, TCTA staff provide trauma-informed, evidence-based mental health treatment for children and adults affected by sexual abuse, children and adults affected by domestic violence, and participants in a program for Juveniles with Problematic Sexual Behavior (Juveniles Starting Over). With a current staff of 12, our clinicians offer services at all four WJCS mental health clinics across the county. Last year, the program treated 241 children and 240 adults.
The professional and societal understanding of childhood sexual abuse and the WJCS program have evolved with increased knowledge, research, and experience in treating survivors of childhood sexual abuse. TCTA is comprised of a multidisciplinary treatment team including psychiatrists, psychologists and social workers. The program provides specialized supervision and training for five graduate students in social work and psychology. During regular weekly meetings, we get an opportunity to learn from each other, present clinical cases, attend to vicarious trauma issues, and foster a strong, cohesive unit. The team borrows a concept from Dialetic Behavior Therapy in using mindfulness exercises to help do this difficult work most effectively while being attentive to self-care.
The TCTA team addresses vicarious trauma issues in an ongoing way, recognizing that to ignore this occupational hazard of working with trauma survivors has great cost. It can be tempting to put discussion of vicarious trauma on the back burner when issues that appear more urgent emerge, but in order to do this work most respectfully and efficiently vicarious trauma must be addressed.
One of the challenges our clinical team has identified is recognition of the limitations of Post-Traumatic Stress Disorder (PTSD) as a diagnosis for many of the adults and children we treat. PTSD is a diagnosis with a history dating to World War I when it was acknowledged that soldiers exposed to war trauma could have “invisible” psychic wounds. It was initially termed “shell shock.” The ability to apply a construct that historically refers to the experiences on a battlefield that happen to adults, and may be the only traumatizing experience of that adult’s life, to adults with more complex trauma histories of child sexual abuse is not always possible.
TCTA staff rarely, if ever, see people who are affected by only one traumatic event. Complex trauma more fully acknowledges that people are often traumatized by multiple and/or chronic and prolonged traumatic events, with an early-life onset, and often they occur within the child’s care-giving system. These traumatic events may include physical, emotional, sexual and educational neglect, and other forms of child maltreatment. Often, this more accurately describes adults seen in our program.
Another area of difficulty in applying a straightforward diagnosis of PTSD is with children. Children are not miniature adults, and it can be misleading to attempt to diagnose a child, especially a young child, separate from the context of his/her relationship with the caregiver. For this reason, we are encouraged by Bessel van der Kolk’s Developmental Trauma Disorder, which attends to the profound importance of attachment relationships in mediating traumatic events. We applaud his efforts to have this diagnosis acknowledged and find it clinically useful when considering the factors that cause a child to be negatively impacted and/or resilient.
Finally, the TCTA program is flexible and clinically sophisticated in providing different treatments for individuals who have experienced trauma. Historically, individual play therapy had been used in addressing trauma in children. While play therapy techniques may be used with skill and effectiveness, we have moved toward a stronger appreciation of evidence-based practice and modalities that maximize parental participation, as much as possible.
The evidence-based practice of Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) has been embraced and mastered by our staff and is the most widely used treatment employed by TCTA clinicians who treat children. All staff are trained in TF-CBT and supervised by adept TF-CBT practitioners. While TF-CBT incorporates parallel child and parent sessions, with the parent and child coming together for sessions at the conclusion of treatment, we also use family therapy, where appropriate, in order to attend to the repair of attachment bonds.
Another recent initiative, funded by the Westchester County Youth Bureau, is a trauma-informed group for parents of young children who have been affected by violence. In attempting to address the treatment barriers experienced by multi-stressed people, we provide child care, dinner and Metrocards to participants. We address a variety of topics, with the goals being to increase the social support experienced by the parents in our group, and to provide them with skills and opportunities to discuss issues related to trauma and parenting young children. It is key to understand that often the most profound way of positively affecting a child’s life is to help strengthen his or her parents.
Our society, and specifically the mental health field, has come a long way in understanding, diagnosing and responding the traumatic impact of childhood sexual abuse on individuals and families. The WJCS Treatment Center for Trauma and Abuse has been in the forefront in Westchester County in promoting this understanding with quality clinical and training programs. The diagnosis of post-traumatic stress disorder has been a part of the evolution in understanding the deleterious impact of abuse on children. However, as our knowledge in this field matures, so must our assessment and diagnostic categories. We look forward to being part of a future that not only promotes a deeper understanding of this problem but keeps pace with new diagnostic categories and new models for treatment that promote healing with a focus on resilience and prevention of further trauma.
Dr. Nelson is Director of The Treatment Center for Trauma & Abuse, a program of Westchester Jewish Community Services (WJCS)