Transcript Salvaging Clinical Connection following Child Abuse Reporting

Salvaging Clinical Connection
following Child Abuse Reporting
October 23, 2013
City of Fremont
Youth & Family
Services (YFS)
Helen H. Hsu,
Psy.D.
Introductions
What type of clinical
populations and settings
are you currently working
with?
Who here has made CPS
(or APS) reports? (ever?
recently?)
Inspiration
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Every licensed therapist
takes the day long
required Child Abuse
Reporting workshop.
When do we ever get to
talk about the work that
happens AFTER the
report(s)?
Objectives
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Overview of history &
review of mandated
reporting
Identify key aspects
damaged in clinical
relationship
Review approaches to
re-engage families
Integrate cultural
competency
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Understand factors for
sound decision
processes following
abuse reporting
Examine case material
with colleagues to
practice clinical
connection repairplanning.
Pop Quiz!
Please take a few
minutes to respond
to items on the
Child Abuse
overview quiz.
Answer each question:
Studies show, in the USA, there are
how many adult survivors of child
sexual abuse?
At which age are children most
victimized?
What is the most common type of
child abuse reported?
Which type of child is most targeted
by child molesters?
Approximately how many children
are found to be substantiated
victims of neglect or abuse per
year in the USA?
Professionals make what
percentage of alleged
abuse/neglect reports?
A Brief History of Child Abuse Reporting in
the USA
• In 1866 Massachusetts passed a law authorizing judges to intervene in a
family when:
“by reason of orphanage or of the neglect, crime, drunkenness, or other
vice of parents’ a child was ‘growing up without education or salutary
control, and in circumstances exposing said child to an idle and dissolute
life.’”
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As early as 1942 Massachusetts had a law authorizing magistrates to
remove children from parents who did not “train up” their children properly
A Brief History of Child Abuse Reporting in
the USA: The landmark case (1874)
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Religious worker Etta Wheeler was notified by neighbors about 9 year old
Mary Ellen Wilson who was being beaten & neglected in New York City’s
Hell’s Kitchen.
Mary Ellen wore insufficient clothing for the cold winter, was beaten, cut
with scissors, malnourished, isolated, confined, and berated by her foster
parents.
Police declined to intervene.
Charities had no authorization to help.
There were no juvenile courts or child protection services in existence
A Brief History of Child Abuse reporting in
the USA
• Wheeler sought advice from
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Henry Bergh, founder of the
American Society for the
Prevention of Cruelty to Animals
(SPCA)
Elbridge Gerry found a legal
means to rescue Mary &
garnered media coverage.
In 1875 the first U.S.
organization devoted entirely to
child protection was
established:The New York
Society for the Prevention of
Cruelty to Children.
The evolution of child abuse as a societal
and community concern
• As of 1965 California still had no
• As news of NYSPCC spread,
county system of child protection
eventually 300 SPCC’s were
organized nationwide
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1962 publication of blockbuster
article The Battered Child
Syndrome by pediatrician Henry
Kemps and colleagues. Kemps
played a leading role to bring
child abuse to national attention
widespread attention in the
1960’s and 1970’s
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Public, political and research
awareness exploded in the
1970’s. By 1967 ALL states had
reporting laws
By 1980’s the Child Protective
System was deluged
Scope of the problem
Child Welfare Dynamic
Report (CA Dept of
Social Services and UC
Berkeley, 2010):
87,000 children
62% neglect
19% physical abuse
9% sexual abuse
10% emotional abuse
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Studies vary- but a
moderate estimate is that
36% of children in a
community based clinic
setting have been
abused.
Overview of Reporting
Neglect: failure of guardian to provide for child’s basic
needs (food, shelter, medical,emotional,education)
Physical abuse: nonaccidental physical injuries to child
inflicted by caregiver or other party (hit,burn,cut,bite,stab,
shake)
Sexual abuse: activities that engage child in sexually
explicit conduct or simulation(pornography, molest,
incest, rape, exploitation)
Emotional abuse: pattern of behaviors that impair child’s
emotional development and self worth.
Who reports?
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Psychologist, physician,
surgeon, intern, EMT, licensed
nurse, MFT and trainee, social
workers and trainee,
psychological assistants
school principal, teacher, coach,
classroom aide, school
employees and volunteers
dentist, hygienist, optometrist,,
podiatrist, chiropractor
police and fire personnel
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public assistance worker
clergy
animal control officers
commercial film processing staff
DA investigator
child visitation monitors
medical examiner and coroner
daycamp or daycare staff and
supervisors
probation officers and staff
Let’s be real: barriers to reporting
● Feeling unsure about
the facts
● Uncooperative or
unavailable child and/or
family members
● Unavailable or unhelpful
family service staff or
police
● Nervous about legal
matters
● Concerns that nothing
will happen - except now
the family abandons
treatment
● Worried that being “in
the system” may be
worse than the current
situation
● Children commonly
rescind statements
To tell or not to tell...the client? Clinical
Considerations
Does your workplace have a policy about this?
Do you have reliable colleagues or
supervisors for prompt consult?
Have you had experience with this?
What is your understanding of the safety of
child/family situation?
Examples...should the clinician tell?
Social worker Rigo works with Tom
and Iris, a homeless couple who
are living in a motel. Both suffer
from severe mood and substance
abuse disorders. Rigo made a
CFS report due to concerns about
their ability to safely care for their
8 month old son.
Therapist Julie is in session with 14
year old Hannah who reveals that
she was “locked out of the house
and hungry” last night when her
parents got angry at her. She
then shares an audio recording of
her parents screaming insults and
awful threats at her.
The next day the couple call Rigo,
“Oh NO! Rigo, you have to help
us! Some *&%# called CPS and
they took the baby!” Rigo can
hear them weeping and
screaming blame at one another.
Julie feels this is reportable. The
parents are waiting outside in the
lobby of the clinic right now.
After the Report-Now what?
Report will be screened
and Categorized:
substantiated
unsubstantiated
no finding
alternative response
intentionally false
unknown.
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Caseworker may:
interview victim
visit home
voluntary service may
be provided
child may be removed
case may be closed
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After the Report
Family Maintenance
Family Reunification
example: children stay in
the home and supportive
services are provided
such as social worker
visits, mandated or
recommended mental
health treatment
example: children have
been removed from
custody, supervised
visitation may take place
while the guardians take
steps to regain custody
such as drug
rehabilitation treatment,
parenting classes
What’s our goal?
U.S. Administration of
Health & Human
Services
“Preferred outcome after
child maltreatment/sexual
abuse is that after
intervention the family
will be intact”
Salvaging The Clinical Relationship
CLIENT REACTIONS
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betrayal
fear
criticism
blame/blamed
persecuted
shame
anger
despair
failure
THERAPIST CONCERNS
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guilt
anger (self)
anger (clients)
danger “lashing out”
responsibility for family
self righteousness
anger
despair
failure
Salvaging the Clinical Relationship
The First Re-frame:
A sentinel event report
does not equal failure!
The Second Re-frame:
don’t despair, there is
hope & opportunity and
we will make an action
plan
Anger
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Identify underlying
emotions
Acknowledge difficulties
and challenges
Enhance skills to reduce
catastrophizing
Re-direct energy to
solving problems
Find strengths
Unraveling the Blame Game
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Help family members feel heard
instead of blamed or judged.
Develop empathy for everyone
on the team - model honesty and
make it OK to have all kinds of
feelings.
Consciousness-raising, how
clearly can clinician address the
team concerns and the step by
step rationale behind
recommendations?
Therapist Self Awareness
PERSPECTIVE
CARE
Does this reporting
scenario trigger strong
reactions for the
clinician?
Utilize supervisor and
colleague viewpoints
Consult the literature
Map or write out plans
When possible, try tp
balance caseload
Be aware of signs of burn
out, whether physical or
emotional
Have a “menu” of
accessible self care tools
Goals of Treatment
● reduce psychiatric
symptoms in parents
● reduce family stress
● improve family cohesion
● address resource
problems
● address social problems
● increase safety for all
family members
● shift power imbalances
in family system
● help family understand
and adapt to cultural
stressors
● plan ahead for risks
● prevent intergenerational
transmission of abuse
What does the data say?
● Parent education
● Relational approach (as
opposed to individual)
● Multi systemic therapy
● Strategic Family
Therapy
● Functional Family
therapy
● Gender sensitive family
therapy
● Therapeutic child care
(ITP)
● Sexual abuse specific
CBT
● collaboration with
colleagues in law
enforcement, child
welfare
Family Engagement
Family involvement is
NOT the same as
Family Engagement
In “involvement” the family is
a helper or adjunct, in
engagement the family is
are empowered key players.
Power differentials are
explicitly addressed.
Case vignettes-discussion questions
● If you choose to report,
● Please work in small
groups, meet at least 1
new person!
● What would be your
immediate next action
step?
● If you choose to report,
tell us WHY
● What were the red flags
& areas of concern?
tell us IF and HOW you
plan to tell the family
● Create a plan for how to
salvage family
engagement and
working rapport.
Case Vignettes #1
“Pei Chen”
12 year old Pei was raised by her grandmother in China. At the age of 5 she
was reunited with her parents in California. Before she was 10, both her
parents business and marriage had failed. Her father had a gambling
addiction & abandoned them. Mrs. Chen, who is monolingual, now
struggles to financially support them. They sleep in the same bed in a tiny
rented room within a house with other boarders near Pei’s school.
Mrs. Chen has developed severe depression. Her psychiatrist Dr. Lee
referred Pei to your children’s clinic. In your 5th session, the family
describes an incident when Mrs. Chen started to push & shove Pei “out of
frustration” when Pei refused to go to school. When you ask about this
incident Pei says “Oh, well that was nothing. The REALLY bad day was
when she slapped me and then was beating me up with a clothes hanger
for stealing money outta her purse. She told me she wanted to get rid of
me-like to an orphanage.”
Case Vignettes #2
“Juan & Luz Flores”
A school principal referred 15 year old Juan to truancy services. His family
are recent immigrants from Mexico. Juan is intellectually disabled so it is
particularly vital that he not miss any special day classes.
You conduct an assessment home visit. The family is friendly and apologizes
for Juan’s absences, but they note that he is very prone to sinus problems
and gets ill a lot.
You become concerned when you see big bruises on Juan’s limbs. Mr. Flores
explains that they had to discipline Juan for “roughhousing” too much with
his 4 year old sister Luz when they were bathing together. Juan reportedly
slipped in the tub while trying to avoid Mrs. Flores.
Juan says “Mom was spanking me with the bath brush ‘cause I pushed Luz
into the water and made her cry.”
Case Vignettes #3
“Georgia Smith”
You have been working with 16 year old Georgia for 5 months. She is a gifted & talented student
who attends private school on scholarship. Georgia suffers from bouts of depression and is very
“stressed out” by her family situation. For the past 3 years Mom has been a “total recluse”
incapacitated by severe depression. All of Mom’s relatives are in Louisiana and they disowned
her 17 years ago for marrying a Black man. Mr. Smith is a Gulf War Veteran who reportedly
“blames us for everything.” The family survives on Dad’s disability and Veteran’s benefits. Georgia
is the only child.
Today you decided to call the Smiths due to concerns about the severity of Georgia’s self injurious
behaviors - cutting and burning herself. Mr. Smith tersely tells you to “mind your own damn
business.” You provide hotline information and try to talk to him about monitoring her safety over
the weekend-- he hangs up.
20 minutes later Georgia calls and tells you never to call their house again- “Dad is super pissed.”
You explain that you called to ensure her safety and she blurts out, “No, just don’t talk to them-they
don’t care! They already know I’ve been cutting, OK?! They didn’t believe me when I got raped at
camp 2 years ago, and they don’t believe I’m depressed now. Don’t you get it? Talking to them
makes it worse.”
Case Vignettes #3
“Amy Fox”
Loretta Fox was a single mom raising her eleven year old daughter Amy, until
she moved in with Jor 5 years ago and they had their son Benji.
You have seen the family for only 3 previous sessions to work on improving
communication. Jor seems impatient and demands the children behave
“perfectly” and clean up after themselves so the apartment looks “like a
magazine picture.”
Loretta shows up for session with only the kids today. She looks haggard and
anxious. She tells you “Jor is dumping us, he moved out 5 days ago.”
When you ask about coping Amy tells you that Loretta whipped both kids
with a belt “a lot” and has been unable to get groceries or cook for them.
Loretta starts to cry and rock back and forth on your couch, “breaking down”
in front of you and the children “Now you’re going to call the cops on me, I’m
a bad parent! No one was there for me when my parents were violent to me!
How come no one ever helps ME?!”
Case Discussions
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Did it feel obvious what
was the correct course
of action?
Did anyone notice a
sense of internal conflict
about what to do?
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Would it feel challenging
to sincerely engage with
these parents?
How would you
approach your work with
this family?
Remember:
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Utilize the treatment
decision matrix along
with your colleagues
and consult team
Model engagement and
sincerity in your clinical
work as much as
possible
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Get cultural consults as
often as possible
Do not ever risk your
own safety! Be realistic
when a case must be
referred out.
Clinicians CAN help families recover from abuse and
learn new ways of interaction
Catherall (1991) wrote that
the key aspect of clinical
work with victims
recovering from abuse
included:
“Re-establishment of a
trusting relationship with
his or her most
immediate experience of
the human community-
THANK YOU!
Helen Hsu, Psy.D.
City of Fremont
Youth & Family
Services
(510) 574-2100
[email protected]