The Message: Book 3 of the Nuclear Survivors Series

Hiroshima by John Hersey – survivors' stories carry weight of history
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On April 26, 1986, the world experienced the worst ever nuclear disaster.

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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. Although group treatment, including Step programs and group therapy, is generally the treatment of choice for individuals who abuse substances Barker and Whitfield, ; Washton, , 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, , p. 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, 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, ; Wald et al. It is also helpful for sexual minorities e. 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, 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, ; Harrison and Morris, ; Krugman, 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. Many alcohol and drug counselors are committed to the 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 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.

In general, self-help groups can be tremendous sources of help for clients with all types of associated problems. 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, 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.

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. 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. 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.

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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.

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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. 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.

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. 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 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. 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.

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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.

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. Turn recording back on. National Center for Biotechnology Information , U. Search term. 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.

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. 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.

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. Timing of Therapeutic Interventions The type of treatment that is most suitable to the individual can be determined in a number of ways.

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. Treatment Techniques Seminal writings about the therapist's contribution to the therapeutic interaction Rogers, ; Traux and Carkhuff, 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.

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. Group Therapy Although group treatment, including Step programs and group therapy, is generally the treatment of choice for individuals who abuse substances Barker and Whitfield, ; Washton, , some individuals with childhood abuse issues may not do well in group settings. 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.

Self-help groups Many alcohol and drug counselors are committed to the Step model; however, that model can be problematic for clients with childhood abuse and neglect. 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. 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. 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.

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. The Importance of Referrals Counselors must be careful not to attempt too much when working with clients with a history of severe abuse.

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. 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.

Recordkeeping Clients' treatment records are important documents. Copyright Notice. In this Page. Treatment Issues Treatment Techniques. Other titles in these collections. Recent Activity. Clear Turn Off Turn On. Support Center Support Center. External link.