Case Studies

My first case study: (Un)Safety in the Context of In-Home Treatment: The Case of a Sexually Abused Childexplored safety, in particular psychological safety in the treatment of sexual abuse. Following this, my second case study: The phenomenological experience of sexual abuse disclosure: Is a child’s sexual abuse disclosure to a parent as traumatic as the actual abuse experience? sought to understand the phenomenological experience of a victim of sexual abuse. Throughout both case studies I noticed the recurring theme of the lack of foundational safety children experience, in addition to non-existent education on how to seek and establish safety. Who is responsible in teaching children that sexual abuse is not OK, and what it looks like when it is happening?

Oftentimes, the most trusted individuals in a child’s life are the most likely to abuse them. There is no discrimination with who potentially could be a perpetrator of sexual abuse. More frequently, we are seeing in the news that those responsible for protecting children- teachers, parents, priests, so on, are in fact perpetrators of sexual violence.

Any response or fight against the epidemic of sexual abuse must be multifaceted, and this project seeks to discover best practices going forward. It is important to notice the damaging effects of a society which promotes sexualized imagery in order to effectively combat its deleterious effects on children.


 The phenomenological experience of sexual abuse disclosure:

Is a child’s sexual abuse disclosure to a parent as traumatic as the actual abuse experience?

Lived experiences inform an individual’s sense of self, others and the world around them. Traumatic experiences have a deep psychological and physical impact, which commonly affects functioning, adaptation and growth in day-to-day life (Van Der Kolk, 2015).  The experience of sexual abuse is a profoundly transformative one. Survivors describe being haunted by fragmented images and splintered memories of sounds, smells, sensations and emotion in sexual abuse disclosures that rarely capture the depth and complexity of the victim’s lived experience. Survivors of child sexual abuse (CSA) struggle with this adversity during crucial formative life stages and can demonstrate significant issues in their development and wellbeing. The typically held belief surrounding sexual abuse is that the actual sexual assault is the core event which contributes to individuals identifying their experience as the traumatic, the source of their struggles or even the underlying cause of mental illness diagnoses. In order to inform the most appropriate therapeutic interventions, CSA survivors may be better understood by exploring their unique phenomenological experience, including what happens after the assault. Through the case vignettes of Preston, McKayla, and Doris, each child will provide their very own interpretation and perception of their experience in an effort to obtain a deeper understanding of a child’s sexual abuse disclosure. These case studies demonstrate how a child’s disclosure of abuse, and the surrounding environment when dealing with this discovery, holds the potential for trauma. In some cases, the experience of disclosure and how this is received by parents and caregivers can potentially become even more traumatic, thus complicating this stereotypical conceptualization of trauma and its impact on survivors of sexual abuse.

The case vignettes provided will not only demonstrate trauma impact, but also complicate how we think of trauma itself. But what exactly is trauma? Trauma is an emotional response to a terrible, abnormal event such as sexual abuse. Psychological injury may occur, damaging the psyche, as a result of this distressing event. Oftentimes, trauma is conceived as one sided- a perpetrator is the abuser, the bad guy, and the actual assault the identified trauma. However, my experiences as a social worker lead me to believe that trauma includes more than the act of sexual assault. Other factors to consider are the act of disclosing the trauma, and, crucially, how ‘we’ as a community respond to it, including family members and health and human service workers. Oftentimes in my work, when listening to individuals share their accounts of their sexual abuse disclosure, I have found that disclosure is often an overwhelming experience. Clients lack ability to cope with the emotions involved within their disclosure experience, thus identifying this experience as traumatic.  Furthermore, all three individuals presented in these case studies identified their disclosure of sexual abuse to their parent as being traumatic and described exacerbated trauma symptoms stemming after their disclosure. All three clients reported an increase in physical and emotional symptoms in the months following their disclosures to their family.

Using a trans-disciplinary framework, the accounts of Preston, McKayla, and Doris will exemplify and illuminate phenomenological experiences of child sexual abuse disclosure.  Through this approach, I sought to empathize with my clients and live in their world, viewing their experiences through their lens. Recurring themes that emerged in therapy include: concepts of self and identity, the emotional impact of disclosure, and physical and psychological symptoms. Prior to their sexual abuse disclosure, Preston McKayla, and Doris lived in silent suffering, resulting in psychological consequences which were exacerbated by their perceived experience of their disclosure.  

McKayla

McKayla, age 14, lived with her mother, stepfather, and her three sisters. McKayla described her childhood as a rollercoaster ride. She had lost count of how many times she moved and how many new schools she attended. McKayla was hesitant to connect with her peers; she made minimal friendships because she knew at any given moment she could lose them. McKayla’s life was erratic. During sessions she elaborated on recurrent experiences of homelessness, bouncing around living with extended family, in hotel rooms, garages, basements, and even her mother’s car.  McKayla and her siblings had a long history of being placed in foster homes due to her mother’s drug use and domestic violence history. After more than nine years of unstable living, McKayla’s mother married shortly after meeting a man while working at a strip bar. The marriage ostensibly provided a stable home and financial stability, which facilitated reunification with her four children. Despite her mother’s marriage having some positive gains and introducing a semblance of stability in her short life, McKayla reported being the primary caregiver for her three young siblings while her mother continued using drugs and had frequent domestic disputes with her husband. McKayla described witnessing years of physical incidents, hearing constant threats and verbal fights, as well as observing the aftermath of blood, bruises, and shards of broken items strewn across the house. Never knowing what would trigger the abuse, she often was fearful, anxious, and always on guard waiting for the next incident. McKayla struggled in school; she was diagnosed with a learning disability and was seen as oppositional and noncompliant with authority. McKayla was reported by her mother as being promiscuous and ‘dating’ older men, including two men who were ten years her senior.  

McKayla eventually disclosed to her mother being sexually abused by her stepfather between the ages of twelve and fourteen. Life changed drastically for McKayla after disclosure: “The moment I told my mother what happened was the day I died. I was no longer the McKayla I used to be or the McKayla I should have been”.  McKayla, scared and embarrassed, hid the sexual abuse she endured by her step-father for nearly two years, but described the disclosure experience as the transformative one. At the age of fourteen, McKayla became pregnant by her stepfather. Fearfully, she met with her doctor, requesting termination of her pregnancy and disclosing the sexual abuse again. McKayla experienced strong, negative emotions during this period: “I felt ashamed, disgusting, and embarrassed”. McKayla was concerned that her experiences of CSA would affect how she would be perceived by others, by the world, and by herself. Certainly, she felt disclosure had changed her mother’s image of her. She had always seen herself as a beautiful, smart, loving, and caring girl. After her disclosure, McKayla’s sense of self shifted, and she reported these previously held core beliefs diminishing into conceptualizing herself as ugly, disgusting, and worthless.

The transformation of a child’s sense of self from a positive to a negative is common among CSA victims. The act of disclosure can have profound impacts on perception of the self for a survivor of CSA. Victims of sexual abuse often experience self-blame, guilt, shame, and commonly take personal responsibility for the abuse. McKayla herself often felt guilty and believed, for the most part, that she had done something terribly wrong as the root cause of her abuse. She evaluated her own behavior as a failure and constantly focused on what she should or could have done differently to avoid sexual abuse.  Consequently, many victims internalize negative messages about their self and identity (Hall & Hall, 2011). McKayla was sure everyone would think poorly about her because of the abuse and told me in session: “I am a terrible person because this happened to me”. In addition to changes in personal perceptions of herself, McKayla told me she believed the entirety of the outside world would view her through that same negative lens after her disclosure, also perceiving her as ugly, worthless and disgusting. Often, shame silences survivors, preventing many from disclosing their abuse. Although McKayla told herself it was not her fault, she struggled with believing it to be true.

Fuchs (2007) describes the experiential “world” as “the totality of life in the sense of an all- embracing framework of meaning in which a person’s experience, thinking and acting are embedded” (p.425). In order for me to fully comprehend McKayla in my role as a social worker, I have to enter her world and envision her horizon. Even when a child’s experience of self deviates from normative or healthy self-perception, these beliefs are meaningful and important (Fuchs, 2007). Introspection, awareness, and understanding of these fundamental beliefs surrounding the self is necessary for any child (Finch, Obst & Vilenica, 2013). For sexually abused children it is especially crucial for them to recognize and become aware of the maladaptive beliefs they hold: “After awareness is brought to what beliefs exist, the beliefs then need to be placed into context by linking them to the event or series of events that shaped the beliefs in the first place” (Finch et al, 2013, p. 52). Children need assistance identifying and challenging the root of their beliefs, including those that were shaped and influenced by their parent’s responses and beliefs as well as wider societal expectations. In addition, children need to know whom they can count on, feel safe with, and feel supported by. Interactions with caregivers help us to know what feels safe and what is safe, and CSA is a dire violation of the necessary physical and emotional safety children require from the adults in their lives. Van Der Kolk (2015) asserts that these interactions with our caregivers are embodied in our brain’s circuitry and form the map of how we think about ourselves and the world around us.  

McKayla’s story provides a heartbreaking example of the ways in which a parent’s attitudes, thoughts and behaviors after disclosure can influence a child’s perception of events and consequently affect how they view themselves, others, and the world around them. But, to what extent do parenting behaviors, reactions and emotions influence a child’s sense of self following their child’s sexual abuse disclosure? Literature on risk and resilience has identified that parenting behaviors are a primary factor in children’s developmental trajectories (Masten, 2001). For example, literature on supportive parenting has been associated with positive child outcomes, suggesting that supportive and engaged parenting behaviors are related to reduced child PTSD symptomatology and increased adjustment following a traumatic event. Conversely, negative parenting is associated with poor adjustment and increased symptomatology, including negative internalizing and externalizing behaviors (Greenberg, 1999 & Brody et al, 2003). Parental responses to disclosure of CSA are themselves consequences of a variety of interpersonal determinants, including the type of relationship with the offender and overall context of abuse. Carnes & Elliot (2001) suggest that non- offending parents vary in terms of their levels of belief, protectiveness, supportiveness, and the distress they exhibit. They suggest there is no typical response to disclosure.  Exploring a parent’s reaction in clinical work is necessary, as their response can affect the child’s recovery process in a negative or positive way. Carnes & Elliot (2001) report that a substantial amount of parents disbelieve some or all of their child’s allegation. They suggest that disbelief and denial are likely given the traumatic impact of a sexual abuse disclosure, and sometimes appropriate. I am hesitant to agree that there is a point in which a parent’s disbelief can ever be appropriate. However, through my experiences as a social worker I have come to understand the challenges parents face with finding it hard to believe an abuser could do such terrible things. Non-abusing caregivers often are left feeling as if they have to take sides, feeling pressure as to who to believe and torn about where their loyalty lies- towards the victim or abuser. This range of parental responses demonstrates as much variability as survivor’s own experiences of CSA and the repercussions of disclosure. Despite some victims displaying minimal effects, others develop psychosocial and behavioral problems including sexual dysfunction, depression, suicidality, trauma symptoms, and substance abuse (Deblinger, Lippmann, & Steer, 1999). Indeed, parental support and responses were identified as a critical component of children’s outcomes in survivors of CSA, with children who are not supported or believed by their parents demonstrating poorer prognosis.

As with many CSA survivors, the phenomenological experience was shaped not only by McKayla’s own thoughts and feelings but by the emotions and behaviors of those around her. Common across many childhood circumstances, a child’s experience and understanding is informed by parental reactions, both behavioral and emotional. When McKayla first disclosed to her mother that she was sexually abused by her stepfather, she reported her mother’s response as ‘unsupportive’, ‘hateful’, and ‘life changing’. Her mother’s initial reaction to the abuse disclosure demonstrated animosity and feelings of betrayal towards her husband. However, that anger and notion of disloyalty soon shifted towards McKayla instead. Her mother had blamed McKayla for the abuse, accusing McKayla of being deceptive. She accused McKayla of intentionally waiting until she was married and cohabiting before disclosure, and viewing McKayla as responsible for her abuse experience, crying “How could you do this to me? ”. McKayla had internalized this reaction and apologized to her mother several times during her disclosure. “I’m sorry mom, it’s all my fault”. McKayla’s mother agreed: “Of course it’s all your fault, how could you allow this to happen”? McKayla’s mother went into crisis mode and she did not work to protect McKayla from the consequences of abuse and disclosure; the ramifications of the abuse meant divorce, homelessness, and a slew of potential negative situations. McKayla’s stepfather denied the allegations, while her mother’s distress provoked suicidal ideation in both McKayla and her mother. [It is worth noting that, although the abuse had been occurring for over 2 years, it is only after her disclosure experience that she communicated suicidality.] Ultimately, McKayla recanted her disclosure after a short period of time.

McKayla felt overwhelmingly guilty, and was concerned that her mother’s dreams and life would unravel. She felt an obligation to prevent that from happening. McKayla’s own distress was exacerbated by confusion, guilt, and betrayal. She often brought up in therapeutic sessions how her experience of disclosure could have been different had her mother not reacted so negatively and demonstrated a severe lack of support. McKayla questioned if this response was normal and asked me if all parents reacted this way. During many of our sessions, McKayla often brought up her mother’s response and felt at fault for her mother’s emotional reactions. Her mother’s behavior following disclosure was extremely salient and heavily emotionally valenced for McKayla, and she reported the experience as incredibly traumatic. She focused on her mother’s thoughts and feelings above her own. McKayla’s sexual abuse disclosure to her mother was received poorly; her mother’s response was wholly unsupportive and placed undue responsibility on McKayla for her own assault. As a result, McKayla divulged significant feelings of guilt, shame, and responsibility for the impact of her abuse on her mother: “My mom was right; I should have told her sooner. I am a terrible child to do this to my mother. Do you think my mother will ever forgive me?”.

Contextual factors, or the ‘lived space’ significantly impacted McKayla’s phenomenological experience of abuse and subsequent disclosure.  Fuchs (2007) concept of lived space provides a lens through which to comprehend the influence of these factors on phenomenological experience. It is described as “the totality of an individual’s spatial and social relationships, including his ‘horizon of possibilities’” (p. 423). In this sense, a child’s lived space is continuously shaped by their exchange with their environment, which contributes to their dynamic development of individual self-concept. Children need a lived space that provides security, love, and connectedness to thrive. In this way, a healthy and normative lived space promotes positive growth and discovery of self in a child. Development of a positive concept of self is vital for all children, particularly those who have been threatened with uncertainty in the face of sexual abuse and who often face difficulties with self development. Negative lived spaces can have devastating impacts. For many children, their memories and experience are enmeshed with their home and lived space. A child’s sexual abuse experience may be considered a distortion of their lived space, resulting in a distorted view of the self and the wider world. Fuchs asserts that in these cases an individual’s development and potentialities are restricted, due to distortions that occurred in the lived space, derived from “unconscious dysfunctional patterns of feeling and behaving” (Fuchs, 2007, p. 423).  McKayla’s lived space comprised the home in which she lived, which was also the space in which she experienced CSA.  Her lived space was therefore characterized as a space of fear, harm, anger, hurt, and unpredictability, which hindered normative discovery of self and the world.  McKayla was unable to identify for me any location in her home she considered a safe place; she viewed her lived space as unpredictable and insecure.  McKayla’s traumatic and negative lived space experience became a fundamental part of her concept of self.

McKayla’s case represents a number of recurrent themes I have experienced as a social worker treating survivors of CSA- the impact on self perception and identity, the effects of parental reactions on disclosure and the influence of a lived space on the child’s phenomenological experience. The following case study, Preston, will demonstrate similar themes in response to CSA throughout his experience with his mother.

Preston

Preston, age 17, lived with his grandparents from birth until the age of 14. His biological parents each had a long history of drug use, alcoholism, incarceration, and domestic disputes. Despite Preston identifying one household in which he grew up, he perceived his home as a revolving door: “My grandparents always allowed my biological parents to come and go as they pleased. From an early age I can remember different family members staying with us. There were times where I shared my room with my parents, aunts, and uncles”. Preston reported frequent police visits to his home throughout his life due to violence and drugs. In contrast, Preston excelled in school; he was smart, an overachiever, and had perfect attendance in spite of his turbulent home life. Despite his academic success, Preston reported using drugs and drinking from the age of eleven. He told me during a session: “My grandparents didn’t care what I did nor did they know some of what I did. I can tell you that the terrible things I did were never as bad as what I’ve seen growing up”.

Preston reported being sexually abused by his grandfather for approximately eight years, beginning at the age of five. Preston was always ambivalent to disclose the sexual abuse to his mother due to her own problematic behaviors. He expressed fear of her relapsing and returning to prison. Preston knew the best time to tell his mother was when she was sober. After much deliberation, Preston had finally worked up the courage to talk with his mother about the abuse after a particularly painful sexual encounter with his grandfather. In therapy, he elaborated on the fear he experienced around telling his mom as he felt she didn’t have the emotional capacity to cope with disclosure in a healthy way. Shortly after Preston’s disclosure to his mother, she overdosed on heroin, and passed away.  During clinical sessions, Preston often expressed feelings of accountability for the death of his mother, which was unforgivable to him: “I should have handled it like a man and kept it to myself.  What kind of person am I? It’s clear I am not worthy of being a son. I am a failure”. This tragic experience so shortly after disclosure compounded the trauma as his worst fears were realized. Similar to McKayla’s experience, parental responses were crucial to Preston’s perception and experience following his disclosure.

“I want to believe you but I just can’t”. These are some of the last words Preston remembers his mother saying before she passed away.  Preston felt betrayed by his mother yet simultaneously felt guilty. He was aware of his mother’s drug problem and was anxious that his disclosure presented a risk to his mother’s stability. Unfortunately, Preston’s fears surrounding his parent’s response to CSA appeared to come true. After a number of painful and difficult years, Preston felt he had had endured enough abuse and planned to disclose to his mother after a particularly intense night in which he reported almost killing his grandfather. He told me: “After I told my mom, there was a lot of silence, and she cried. I never cried- men don’t cry”. He remembered waiting what felt like a lifetime for her response and when it finally came, his mother’s reaction made him wish he had stayed silent. Preston’s mother became explosive, questioning her father’s and Preston’s sexual orientation. In disbelief, she questioned Preston’s motives and accused him of fabrication, in line with common negative parental responses indicated by Carnes & Elliot (2001).  Echoing McKayla’s story, Preston experienced feelings of responsibility and accountability, both for the abuse and for his mother’s reaction, and a compulsion to apologize for his ordeal. While repeatedly saying sorry to his mother, Preston remembered begging his mother not to turn to drugs as he battled the painful memories flooding his cognition. Preston recalls his feelings after his mother’s response, and how her beliefs shaped his perception and opinion of himself following disclosure, a transformative process shared by many survivors (Van Der Kolk, 2015): “I felt ashamed and confused. Was she right- did this mean I was gay? Was everyone going to think I was gay”? Like McKayla, Preston questioned himself and who he was as a person- he felt disgusted and embarrassed and believed outsiders would concur. During our sessions, I asked Preston what he wanted from his mother:  “I don’t know what I wanted her to say. At the time, I remember thinking I wanted her to hug me and tell me how sorry she was. I wanted her to understand how much pain I was in and how broken I was”. Even now, two years later, Preston regrets his disclosure. He often brings up in therapy how different his life could have been had he not told anyone. This concept is rarely framed through the lens of how different his life would be had he not been abused and victimized. He believed that, without disclosure, his mother would still be alive, his family wouldn’t hate him, and maybe he wouldn’t hate himself. Preston hated himself for telling his mother and he hated himself for allowing everything to happen. In sessions, he often revisited how angry he felt with how his mother responded to him. “I will never forget the day I told my mother. Sometimes I think how she responded has hurt more than the abuse”.  

Survivors of CSA often describe similar emotional experiences. Two which stand out in the cases of McKayla and Preston are shame and an inability to feel appropriate emotions, or dissociation. Preston spoke often of wanting to feel alive again; he felt imprisoned in his past. Consequently, unable to feel energized in the present, he remained hostage to his history. As Van Der Kolk asserts (2015, p.13) “It’s hard enough to face the suffering that has been inflicted by others, but deep down many traumatized people are even more haunted by the shame they feel about what they themselves did or did not do under circumstances”. Preston frequently mentioned feeling ashamed for allowing his grandfather to abuse him for so many years, and felt he was somehow responsible or complicit in his abuse. Additionally, he was ashamed for disclosing the abuse to his mother rather than ‘handling it like a real man’ and remaining silent. Early in treatment, shame was the only feeling that made Preston feel alive. During sessions, Preston brought up several times the numbness and dissociation he constantly felt, especially at his mother’s funeral. “I felt like a monster- I didn’t feel as if I was human. I didn’t shed a tear”. As we worked together in a clinical setting, Preston was able to recognize that his emotional experience was deeply rooted in his traumatic experiences, as well as his family’s response to them, in line with Finch, Obst & Vilenica (2013). While assisting Preston in observing his sensations and feeling his emotions, we processed their emergence, and how to gain control. For Preston, remaining silent was his way of controlling his shame and exercising autonomy over his experience.  

Preston also experiences significant physical issues as a result of being a victim of CSA. Hiding in silence from the abuse he endured, Preston became vulnerable to react to triggers; his body responded to the hormones that signaled danger (Van Der Kolk, 2015). Preston’s way of remaining in control consisted of avoiding adult males and reacting explosively to male authority. Preston remembered a time in which he knocked over his desk in class and left school after being instructed by his male teacher to remove his headphones. He later apologized for his behaviors but remained confused as to why he reacted so explosively to a simple, benign request. He avoided staying after class for extra help and was suspended for failing to serve a detention with a male teacher. While Preston worked to hide his core emotions, stress hormones constantly flooded his body leading to physical manifestations of the stress, including complaints of headaches, problematic bowel function, and muscle aches. Preston developed the survival strategy of pushing away any feelings he had and focused on excelling academically. He worked on suppressing his feelings as a protective mechanism- for Preston it was safer to feel ashamed and hate himself than risk the repercussions of expressing his feelings about his family and his abuse. According to Van Der Kolk (2015) as a result he is likely to grow up believing he is fundamentally unlovable which is the only way his mind could explain the horrific abuse he endured. Preston survived for years by suppressing his anger and forgetting the abuse. Preston avoided relationships, both romantic and platonic- he feared getting hurt or betrayed.

Preston’s story shares a number of similar themes with McKayla’s. Distortion of the survivor’s sense of self due to the abuse and a phenomenological experience shaped by parental reactions to disclosure characterize these vignettes. There are many advantages to a child disclosing their sexual abuse to their parent and, conversely, many dangers associated with not disclosing. However, equally as important is considering the advantages and dangers the disclosure will pose to a child when the response is unsupportive, negative, or as seen in this case, traumatizing. Additionally, Preston’s case highlights the ways in which CSA can impact physical health as well as psychological wellbeing. The case of Doris provides further evidence that, while unique, a child’s phenomenological experience of CSA and disclosure can share many themes across the cases I encounter in my position as a therapist.

Doris

Doris, age 15, lived with her mother, two siblings, and her mother’s boyfriend. She reported moving frequently throughout her childhood to whomever boyfriend’s house her mother was with at the time, counting at least twelve homes in which she observed frequent physical domestic disputes. Doris described a poor relationship with her mother and repeatedly spoke about being angry about her mother’s poor choices and behaviors.  For example, her mother exhibited a number of maladaptive behaviors around romantic relationships- she bounced from one bad relationship to another and periodically left Doris and her siblings with the abusive boyfriend, returning once in a new relationship. As in Preston’s case, Doris’ mother struggled with depression and substance abuse, and Doris felt culpable. Like McKayla, parentification occurred and she assumed the role of protector and caregiver for her siblings.

Doris disclosed sexual abuse to her mother that had been occurring since she was eight by one of her mother’s on and off again boyfriends, John. Doris wanted to see her mother happy after years of watching her parent battle depression and alcoholism. She perceived herself as a courageous and compliant child that followed John’s orders to remain silent. She had been told she was brave and if she disclosed her secret, she would no longer be brave. But, after a violent sexual encounter with John, Doris went to her mother for help, confused as to why she was bleeding uncontrollably. It was then that Doris accidentally disclosed the on-going abuse. Doris displayed parallel emotions to McKayla and Preston. She told me of feeling dirty, embarrassed, and completely humiliated, and a strong compulsion to run away. Doris told me she wanted to run from a world she felt would never see her in the same way. Again, themes emerge across survivors as Doris demonstrated feelings of shame and embarrassment, changes to a previously positive self-perception and fears that other people in the wider world will also perceive her negatively as a result of experience and disclosure of CSA.

Doris recalled to me going to the bathroom in a lot of pain, confused about bleeding so much. Not knowing what to do she had called her mother for help. Here we can see another example of the devastating impact of parental response on a child’s phenomenological experience following disclosure of CSA. Her mother asked her a lot of questions – many pertaining to if she was sexually active. Doris’s mother knew she had never had a boyfriend before. It was then that Doris reluctantly told her mother about the sexual engagements with John.  Her mother responded negatively and did not support her daughter. Enraged, Doris’s mother began screaming and yelling and forced her boyfriend John to come upstairs to the bathroom. Doris recounted feeling scared and confused about why she called him upstairs. Doris broke down in tears, shaking in session while describing the altercation that took place in the bathroom.  She described her mother aggressively hitting and screaming at John while questioning him.  John, intoxicated as always, facetiously exclaimed “who wouldn’t want to have sex with me?”. Doris’s mother quickly turned on Doris, hitting and screaming questions about how many other boyfriends she seduced. Her mother went on to express her hatred towards Doris. Wiping her tears during our session, she laughed bitterly as she remembered her mother asking her who was going to call the police and tell them how she liked to screw her mother’s boyfriends. In response to her mother’s reaction, Doris recalled experiencing similar sensations of dissociation as described to me by Preston, telling me she felt frozen and then dead, as if she had no life in her.  Additionally, in line with both Preston and McKayla’s experience, she expressed feelings of responsibility, shame, and guilt, as if she had betrayed her own mother. Despite internalizing this negative and traumatic reaction, Doris struggled with accepting the view that the abuse was all her fault. She questioned me why her mother never asked when it began as this was significant to Doris. Doris wanted her mother to recognize she was only eight years old when it began. She wanted her mother to tell her that an eight-year-old child could not be at fault.  

Like Preston, Doris described considerable physical symptoms. Stored in Doris’s memory were fragmented images and feelings of the traumatic sexual abuse she endured. Daytime offered no relief for Doris as she reported constantly being triggered with intrusive thoughts, memories and frequent flashbacks; nighttime was interrupted by horror-fueled dreams and cold sweats. Doris was afraid to sleep at night; she feared the nightmares that felt as real as reliving the abuse, and sometimes worse than the abuse itself. Consequently, after restless sleep replete with nightmares, the days that followed were exacerbated by hypervigilance, mood dysregulation, and intense distress.  In child survivors of sexual abuse, the memory of helplessness can be stored as muscle tension or feelings of disintegration in their vagina and rectum (Van Der Kolk, 2015). Doris often complained of pain in her abdominal and vagina areas. After six months of trauma therapy with me, Doris was able to recognize her trauma symptoms as such. As I listened to her, I wondered if all my clients endured similar symptoms yet lacked the ability to identify and express them as articulately Doris was able to. I wondered if they, too, were unable to find peace in their daily lives.

Doris had learned to ignore her feelings after being rejected and unsupported by her mother following her disclosure. Because her mother had turned on her she was forced to find alternative ways to cope with her fear, anger, guilt, and shame. When managing terror alone, dissociation, disconnection, explosions, and despair will arise as a result. Often clients are unable to make the connection between their present feelings and actions and what happened in their past (Van Der Kolk, 2015). Certainly, these mental states were clear during my clinical work. During sessions with Doris, she was gradually able to regulate herself and remain calm while expressing her anger and confusion towards her mother and abuser. Like Preston, she spoke of numbness and dissociation. As Van Der Kolk asserts, “[d]issociation is the essence of trauma. The overwhelming experience is split off and fragmented, so that the emotions, sounds, images, thoughts, and physical sensations related to the trauma take on a life of their own” (p. 66). Doris’s accounts in session demonstrated sensory fragments intruding in her present life through her thoughts and memories. Intrusive sensory fragments forced her to re-experience the horrific abuse- the smell of cigarettes, the sound of rock music, and the click of a key being turned in the lock of a door. She told me of the nights she was wrenched awake by half-formed memories, drenched in sweat and feeling newly violated. Our bodies secrete stress hormones for self-protection; as Doris’s trauma remained unresolved, her hormones continued to circulate, enabling the defensive movements and emotional responses to continue replaying (Van Der Kolk, 2015).  As Doris and I worked on reducing and alleviating the distress of her flashbacks, she spoke of the routines she created to protect herself against them. At night, Doris found herself engaging in self harm behaviors- while cutting into her wrists, she had control over the knife and pain she endured- she controlled the intensity and duration- and most of all, she had the control. Doris was exhausted- fragments of the sexual abuse replayed constantly preventing her from rest and stress hormones engraved her memories, rooted deeply in her mind. (Van Der Kolk, 2015).

Parental attitudes and behavior following a CSA disclosure can drastically shape a child’s recovery and health. In general, the term ‘empathy’ is defined as the ability to understand and share another’s emotional state, which includes both a cognitive and affective component (Cohen and Strayer, 1996; Hoffman, 2001). Similarly, Hoffman (2001) describes empathy as a “first-person-like, experiential understanding of another person’s perspective” (p. 85). Most theories of empathy argue that both parties must have an experience in common in which “one comes to understand another person’s experience by having a similar experience” (Ratcliffe, 2013, p.69). Doris and McKayla’s mother were both victims of sexual abuse. Despite this, they carried their history into their initial reaction during their children’s disclosure. Both parents recalled a lack of support from their families and, although they still felt anger about it, responded to their own children in similar ways. Although these parents shared an extremely similar experience with their daughters, Doris and McKayla’s mothers needed to be supported and nurtured during our work together so that in return, they could nurture and support their children. At the time of McKayla and Doris’s disclosures, their mothers did not have the emotional capacity to support them. Through a trauma informed lens, McKayla and Doris’s mothers’ responses can be seen as avoiding the pain of reliving their own experience by disbelieving it could happen to their children. Hollan (2008) argues “empathy requires the imagination of someone willing and able to be understood, as well as someone who makes an effort to understand” (p. 483). When it comes to something as traumatic as CSA, empathy can be precluded by issues with understanding. For example, many children struggle to comprehend their abuse or to articulate it clearly. During a sexual abuse disclosure, it is hard to imagine a distressed or triggered parent who expresses disbelief also keeping the needs of their child at the forefront and simultaneously attempting to understand the situation. There is constant shift of focus and refocus on what information the parent requires in order to be in a position to be willing to understand. Consequently, not all individuals allow themselves to be understood (Hollan, 2008, p. 487): “We cannot expect much help from those we are trying to empathize with”. The empathic work of understanding suggests it is dependent on the emotional, imaginative, or mind reading capabilities of the empathizer (Hollan, 2008). Hollan asserts “if empathy is embedded in an intersubjective encounter that necessitates ongoing dialog for its accuracy, then it implicates the imaginative and emotional capacities of the person to be understood as well” (p.487). During a session with Preston, McKayla, and Doris, I asked if they felt their mothers were empathetic to their sexual abuse experience. All three children had difficulties responding to the question. Consequently, when I asked if they felt empathetic to their parent’s response, each child had similar difficulties responding. It is worth noting again that both McKayla and Doris’s mother had been victims of child sexual abuse. Although they shared similar experiences with their child, their ability to empathize was non-existent according to McKayla and Doris’s accounts. In fact, these women had aggressively blamed their children for the abuse. Just as it is important to understand how parents empathize with their children, we also need to understand how the children “allow themselves to be known and understood” (Hollan, 2008, p.487). Preston, McKayla, and Doris wanted their parents to understand them, even in cases where they had failed to protect them from the abuse. All three children struggled with the ability to find the language to express their silent suffering. Consequently, each child’s attempt to be understood was unrecognized, and each parent in turn failed to make an effort to understand. The above accounts reveal this experience.

The reactions of those around them contribute to the ways in which children understand and make meaning of their experiences. When caregivers fail to respond in healthy or normative ways to CSA disclosure, survivors often turn inward in their search for an explanation for the abuse. Abandoned by the parents who were most crucial to their recovery, Preston, McKayla, and Doris were driven deeper into self-hate and self-blame. Their attempts to face the reality of their horrific experiences were hindered by blame, shame, and the rejection they experienced from their parents. Their attempt to cope contradicted their parents entrenched beliefs and expectations around the perpetrator and instead stigmatized the child, perceiving survivors as liars and manipulators instead (Summit, 1983). Child sexual abuse accommodation syndrome (Summit, 1983) describes how sexually abused children commonly attempt to resolve their experience of sexual abuse in relation to disclosure. Summit described five stages:  Secrecy, Helplessness, Entrapment and accommodation, Delayed disclosure, and Retraction. At the heart of Preston, McKayla, and Doris’s phenomenological experience is their meaning making process. Betrayal of love and trust can shock even the most well-adjusted and emotionally developed adult- how does a child make sense of this? The child sexual abuse survivors I work with require empathy, respect, and attunement while working with them through their journey of meaning making. It is vital that I have an appropriate reaction to their disclosure to begin establishing a therapeutic connection. My reaction and response to my client’s disclosure can either inhibit treatment or be a healing agent for recovery.  Utilizing Dr. Summit’s theory, child sexual abuse accommodation syndrome, the cases of Preston, McKayla, and Doris shed light into their subjective experience during their meaning making process:

Secrecy: Preston, McKayla, and Doris each felt it was their responsibility to keep their abuse a secret in order to keep their family stable and together. Although they knew their abuse was wrong, they feared the repercussions of disclosing. They learned to suffer in silence, as they believed this would make everything all right or eventually go away.

Helplessness: The fear of losing their family contributed to remaining silent. Preston, McKayla, and Doris were young, emotionally immature, and dependent on their caregivers; they were unable to see an escape from their abuse which did not impact other family members and the world around them. They perceived their abusers as powerful and attempts to protect themselves from the ongoing sexual assaults always seemed to fail. Consequently, after ongoing attempts to protect themselves resulted with failure, the expectation of being helpless emerged and was reflected in their actions.

Entrapment and Accommodation: Suffering through years of victimization, Preston, McKayla, and Doris began to accept their abuse as a normal part of their life and focused on surviving. At the time, they were unable to make sense of how someone who loved and cared about them would abuse them, and later, how their disclosure could be rejected by a caregiver whom they had seen as their protector. Each child reported a variety of behavioral accommodations in order to survive the non-normative lived space they inhabited. Doris reported dissociating from herself and body during her abuse- eventually feeling nothing. While escaping mentally, her body no longer felt the physical hurt while being assaulted.  Eventually, Doris was able to block out the abuse entirely until it revisited her subconscious, transforming her dreams into nightmares. McKayla felt if she behaved better, her abuser would love her more, and if he loved her then he would stop causing her pain. Preston went into survival mode.

Delayed, Conflicted and Unconvincing Disclosure:  Preston, McKayla, and Doris feared not being believed by their parents. Unfortunately, these fears came to fruition. In sessions, they imagined a perfect day in which they could disclose without risk to themselves or families. During disclosures, accounts were fragmented, words were scattered, and memories were hard to articulate.  

Retraction: The guilt McKayla was made to feel as a consequence of her mother’s reaction after her disclosure lead to her retracting her confession. She didn’t want to destroy her family and felt it was her responsibility to protect her mother.  Although flooded with fear, betrayal, shame, and guilt, Preston and Doris did not retract their accounts.

Therapeutic intervention offers an opportunity for CSA survivors to work through healthy meaning-making processes in order to comprehend their experiences and move on. However, this is not inherently desirable to some survivors. Early in treatment, Doris expressed beliefs that re-experiencing her sexual abuse experience by talking about it in therapy would have a negative impact on her well being. She openly refused to process the meaning making of her experience: “I have shut out all the painful memories I once had. I was defenseless and vulnerable before and I will not endure that experience again”.  The language Doris used was essential to my understanding of her subjective experience of the process of meaning making. I had to comprehend Doris within the context of her own development and individual process in order to provide effective clinical treatment. Frequently, children who have been sexually abused push away their thoughts of the experience in an effort to move on as if nothing happened: “It takes tremendous energy to keep functioning while carrying the memory of terror, and shame of utter weakness and vulnerability” (Van der Kolk, 2015, p. 2).  Doris was unable to recognize that her current thoughts, feelings, and the physical sensations she was experiencing were taking on a life of their very own. During sessions, I attempted to bring awareness to her physical and emotional reactions; Doris expressed the anxiety it created for her to be mindful and attuned with these feelings. She feared letting go of the defenses her body built.  Doris believed that being mindful of her internal sensations and emotions increased flashbacks. She angrily told me that every time she had tried practicing being mindful she had flashbacks of John raping her, and found herself binging on whatever food she could find in the kitchen in response; Doris had gained 45 pounds since her disclosure. I asked Doris if she was able to recognize that she was using food to cope with feelings and emotions that she could not tolerate. “When I look in the mirror I don’t see myself, I don’t want to see the old Doris”. As Doris watched her body change she also found a new identity, a new Doris. As Doris focused on viewing herself from the outside and noticing drastic change, she struggled with recognizing her inside was still the same. She continued to avoid intolerable feelings resorting to frequent binge eating and terminated her treatment sessions with me. Several months later, I received a phone call from a distraught Doris: “I don’t understand what is happening to me or around me, I need help”.  

In contrast, during treatment Preston and McKayla immediately expressed the desire to make sense and find meaning in their experience. Traumatic experiences leave traces on our minds and emotions, on our ability to feel joy and experience intimacy, and on our biology and immune system (Van Der Kolk, 2015). Preston often expressed his need to find the will to continue living. McKayla expressed her desire to understand why she has trouble connecting and trusting others.  After some time, Doris too wanted to make sense of what was happening to her and around her.

CSA survivors often find the stress of their abuse manifesting in maladaptive thought and behavior patterns that meaning making exercises can ameliorate. Chief presenting complaints that emerged in therapy sessions included a variety of psychological problems such as dissociative symptoms, feelings of shame, blame, anger, and fear, loss of previous sustained beliefs, emotional numbing, and affect dysregulation. Through their meaning making process, McKayla, Preston, and Doris were able to make sense of their emotions following CSA and disclosure. Meaning making allowed them to disentangle their current behavior from past experiences, such as poor ability to set boundaries and limits with others. Through therapy, they were now able to understand they were not able to control what the terrible things that happened to them and that their personal boundaries were violated by someone they trusted, which had led to reduced ability to set boundaries with others. Preston was able to make meaning out of his anger; he now understood he could feel confident when experiencing anger rather than seeing this emotion as powerless, with little effect, as it was previously with his abuser. He was able to grieve the loss of his mother, childhood, and his innocence that was ripped away from him. Ultimately, Preston was able to let go of the guilt and shame he carried. Over the course of our sessions he accepted that it was not his fault.  He could not stop the abuse nor did he allow his silence and delayed disclosure to hinder letting go of his shame. McKayla was beginning to be able to trust again. She realized her self-esteem had increased once she was no longer internalizing her abuser’s negative comments. Foremost, McKayla was able to develop healthy coping skills rather than continuing the maladaptive coping skills she used to manage her trauma. Similarly, Doris no longer suffered with binge eating as she gained development of new skills to cope with her trauma.

Memories of the abuse were experienced through the body; over time McKayla, Preston, and Doris were able to make the connection between their mind and body when experiencing physical problems. The headaches, dizziness, and abdominal pains were not psychosomatic, but their bodies being hijacked and defending their abuse from their past. Once they engaged in meaning making around CSA, these physical symptoms abated too. As Van Der Kolk asserts, “[t]his explains why it is critical for trauma treatment to engage the entire organism, body, mind, and brain” (2015, p. 53).

Conclusion

Child sexual abuse involves multifaceted forms of abuse which can lead to long-term emotional, social, psychological and physical consequences. The stories of McKayla, Preston, and Doris capture the essence of their phenomenology experience. They shared their deepest pain through our therapeutic relationship, unspoken words were discovered and replaced their silence, and they found healing in their darkest space. After being held hostage by their experiences, silenced and ignored, gaining control over their ability to communicate in the fullest form and share their deepest pain was foundational to understanding their phenomenology experience.

In addition to exploring the effects of the experience of sexual abuse and disclosure on a child, it is equally necessary to explore the impact of the parents’ reaction during the disclosure. Within treatment, I have seen a variety of responses from parents when discussing their child’s sexual abuse disclosure and I recognize how crucial it is to understand the parent’s emotions and reactions as a therapist in an effort to better understand the child victim’s experience. A parent’s reaction after a disclosure of sexual abuse influences the child’s experience of emotions, reactions, and recovery process. But to what extent is a child victim’s recovery predetermined, and dependent on their caregiver’s reactions and support after the abuse disclosure? The phenomenological experience of a response after a disclosure, or lack thereof, requires a deeper understanding when working with and understanding the experience of a child victim of sexual abuse. The cases presented demonstrated how each individual’s disclosure was uniquely damaging. The effects on their well-being, self concept, beliefs about others and the world, and their relationships, seem distinct from the those incurred through experience of CSA itself. The disclosure experiences of Preston, Mckayla, and Doris represented a mismatch of what should have occurred in a healthy and normative parental reaction (support, empathy, active listening), and what actually did (rejection, disbelief, lack of empathy, and an absence of support).  In other words, while their disclosure represented courage, strength and belief in the self for these children to put into words what they could barely speak, they were met with rejection and lack of support. This mismatch can itself feel deeply traumatizing, evoking fear, shame, and guilt. These case studies illuminate the ways in which the trauma experienced by CSA survivors is often greater than the sum of sexual and physical violence. The act of disclosure and the consequences of speaking out about CSA hold immense potential for additional trauma, thus complicating how we perceive trauma in the field. Hence, to be deeply understood one requires an active empathetic listener with the education on how to respond therapeutically to a sexual abuse disclosure.  It is this case study’s hope that, through the subjective experiences provided, we gain knowledge and understanding of a child’s sexual abuse disclosure and experience from their perspective.

References:

Brody, G., Conger, R., Ge, X., Gibbons, G., Kim, I., & Simons, R. (2003). Parenting Behaviors

and the Occurrence and Co-Occurrence of Depressive Symptoms and Conduct Problems

Among African American Children. Journal of Family Psychology, 2003, 17 (4),

571-583

Cohen D, Strayer J. 1996. Empathy in conduct-disordered and comparison youth. Developmental

Psychopatholgy 32:,88–99.

Deblinger, E., Hathaway, C. R., Lippmann, J., & Steer, R. (1993). Psychosocial characteristics

and correlates of symptom distress in nonoffending mothers of sexually abused children.

Journal of Interpersonal Violence, 8, 155168.

Deblinger, E,. Steer, R., & Lippmann, J. (1999a). Maternal factors associated with

sexually-abused children’s psychosocial adjustment. Child Maltreatment, 4, 1320.

Elliott, A., Carnes, C (2001). Reactions of nonoffending parents to the sexual abuse of their child: a review of the literature. Child Maltreatment. 6 (4), 314-331.

Fuchs, T. (2007). Psychotherapy of the lived space: A phenomenological and ecological concept.

American Journal of Psychotherapy, 61(4), 423–439.

Greenberg, M. (1999). Attachment and psychopathology in childhood. Handbook of attachment:

Theory, research, and clinical applications. New York, NY, US: Guilford

Press

Hall, M., & Hall, J. (2011). The long-term effects of childhood sexual abuse: Counseling

implications. Retrieved from http://counselingoutfitters.com/vistas/vistas11/Article_19.pdf

Hiebert-Murphy, D. (2000). Factors related to mothers’ perceptions of parenting

Following their children’s disclosures of sexual abuse. Child Maltreatment, 5, 251260.

Hollan D. (2008).“Being there: on the imaginative aspects of understanding others and being

understood,” Ethos, 36(4), 475489.

Masten, A. (2001). Ordinary magic: Resilience processes in development. American Psychology,

56(3), 227-38.

Summit, R.C. The child sexual abuse accommodation syndrome. Child Abuse & Neglect.

7,177–193.

van der Kolk, B.A. (2015) The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma. Penguin Books.

Vilenica, S., Shakespeare-Finch, J., & Obst, P. (2013). Exploring the process of meaning making

in healing and growth after childhood sexual assault: A case study approach. Counselling

          Psychology Quarterly, 26(1), 39-54.


(Un)Safety in the Context of In-Home Treatment:

The Case of a Sexually Abused Child

                                                                     Abstract

Through the case of Becky, a victim of sexual abuse, this case study will explore in-home therapy safety concerns and the responsibilities of agencies and institutions to secure the safety of in-home therapists. Clinical experience and data will demonstrate and explore the difficulties of ensuring safety and implementing safety guidelines. This paper will demonstrate the limitations of ensuring worker safety in the context of in-home therapy treatment including: the difficulties with ensuring safety and implementing safety guidelines, the absence of a working alliance, worker safety is compromised, and the impossibility of worker safety in the absence of a working alliance. I will also explore the relationship between countertransference and safety. A therapist must be able to recognize problematic countertransference reactions and manage them effectively.


I beeped my keys three times to make sure my car was locked and shot a look of primal fear through the rear window, worried that the empty child seat in the back might expose my vulnerabilities.  I scanned the façade of my client’s residence.  Metal poles, like the kind you would find in a jail cell, secured the windows.  My mind raced through its usual checklist of trepidations.  Could someone run my license plate to find out where I live?  How fast could I get back to my car, just in case?  With each step toward the door, I double-checked my cell phone, wondering if anyone from my agency knew I would be here today.  A child screamed.  A woman cursed.  The stench of marijuana could not mask the distinct scent of urine that permeated the air.  I found the door, pocked with a bullet holes, and knocked.  It was another day at the office for me in my job as an in-home therapist.  I can’t seem to get used to it, but I suppose that this is my normal.

        “Who?”  That’s what the man yelled from inside.  I said my name with any resolve I had inside me cracking.  All of my instincts told me to turn around.  But just then, Becky, the twelve-year-old little girl I was here to help, opened the door, and I smiled warmly, feigning indifference to the dirty diapers on the floor, the trash in the stairwell, and the cockroaches crawling on the wall.  I acknowledged, with a pause, the man yelling in the background: “I told you we don’t need a shrink coming up in here, knowing our business and telling us what to do!”  I kept myself from flinching visibly as a way to respect Becky’s normal.

        Becky waved me inside and directed me to sit on a flea-infested couch.  As she double-padlocked the door and began to piece together a puzzle of gold-colored security chains, I tried to distract myself from the fact that I was now locked inside with her.  I reviewed what I knew from Becky’s file in my head.  I was here because Becky had been exhibiting over-sexualized behavior in school.  Her parents—presumably the people who could not stop arguing about my presence in their home—had no transportation and were unable to bring Becky to the office.  I was truly meeting my client where she was: stuck in a low-income housing project replete with gang violence, drug activity, 11 registered sexual offenders, and no easy way out.  I felt that if I could hide my discomfort, then maybe we could both keep pretending that we would engage in normal therapy.

        But who am I kidding?  In-home therapy is not normal therapy.  As my prologue suggests, the real issue for me is that there is no sense of safety.  When the forebears of social work conducted their friendly visits, I must imagine that they faced very difficult but very different circumstances. Now that visiting has evolved, in many cases, into a state-sponsored initiative in the twenty-first century, I know that I will be viewed not as a therapist but as a snitch, an intruder, a spy sent in to sniff out illegal behaviors, someone who comes to take a child away from a family.  Indeed, per agency policy, I must call the police if I feel that my well-being or the physical safety of my client is at risk.  Without any control of the environment,  I almost always feel that I am in danger.  Conducting therapy in unsafe situations, however, is part of clinical social work.  In-home therapists play a vital role in making treatment possible when clients and their families lack transportation, lack childcare, and lack the understanding of why therapy is needed.  In-home therapy makes it possible for the government to make services convenient in situations where the  client cannot handle any more struggle.  Though it seems counterintuitive to place a social worker in danger for a matter of convenience, there is often no other viable way to reach some of the most desperate clients.  It is not usually possible or preferable to remove clients, who feel dignity with autonomy, from their unsafe situations.

I write to bring awareness to the importance of in-home therapy but with a call for the state to recognize the need for better safety guidelines and protocols in place for conducting in-home therapy. In addition, I aim to help clinicians to understand the potential risks and benefits of ensuring safety while managing countertransference and establishing a working alliance.  In home therapy clinicians need to consider personal safety, as well as client safety, during application of clinical treatment. We need to balance the risks and rewards of in-home therapy.  I offer Becky’s case, a victim of sexual abuse, and my experience working with her, to make this point.

Literature Review

In-home therapists put themselves in harm’s way each day in an effort to help our clients in their most vulnerable state. Not only do therapists work with a vulnerable at risk population, but for many families, therapy services are court ordered resulting in anger provoking situations. Therapists often enter these situations alone without a partner, and with little or no safety training. Safety is an area that is not comprehensively covered in school nor within state or local agencies to secure in-home therapist safety. In-home therapists are expected to enter the lives of families when they are at their worst, solve seemingly intractable problems, and help clients with life-threatening challenges and work with them at their most vulnerable moments (Kelly, 2010). Many of the skills required to assure safety and implement safety guidelines are learned with field experience. But in-home social work is a dangerous profession that has increased with assaults and deaths of clinicians.

The National Association of Social Workers of Massachusetts, (NASW-MA) provides policy recommendations to reduce risk to clients, direct service staff, management, and administration. Policy recommendations include: the development of professional skills related to risk assessment and safety promotion, develop safety policies in agencies, the development of safety policies in schools of social work, and advocating for legislation and state guidelines. Risk reduction and safety promotion include skill development in: risk assessment, safety planning, de-escalation techniques, and non-violent defense. In addition, therapists are encouraged to obtain education and training in cultural competence and historical, political, and economic contexts that may impact safety considerations, individual actions, and agency policies and procedures (NASW, 2001).  Despite these recommendations, it is important that therapists accept the reality that violence is inevitable, and it occurs in social work practice (Ringstad, 2005).

The recent murders of social workers in Massachusetts, Kentucky and West Virginia have prompted state legislation to promote workplace safety for social workers. State NASW chapters and local social work activists continue to fight for state legislation, federal legislation, and state guidelines (NASW, 2014). Despite this, only three states, California, New Jersey and Washington, have guidelines that address workplace security and safety for social workers and other workers. Among these guidelines, employers are required to put in place specific safeguards to reduce risk to social workers (NASW, 2014). NASW President James J. Kelly, PhD, ACSW, LCSW, noted, “In the past few years alone, we have witnessed the fatal stabbing of a clinical social worker in Boston, the deadly beating of a social service aide in Kentucky, the sexual assault and murder of a social worker in West Virginia, the shooting of a clinical social worker and Navy Commander at a mental health clinic in Baghdad, and the brutal slaying of social worker Teri Zenner in Kansas. These are only a few of the murders of our colleagues, which, along with numerous assaults and threats of violence, paint a troubling picture for the profession” (Kelly, 2010). Hence, state guidelines to address safety continue to be yet established and safety continues to be a topic minimized at local agencies until provoked by a tragedy.

Recently, in an effort to support in-home therapist safety, state legislation prompted a focus on prevention of assault in the workplace and in the field.  Massachusetts state legislature passed “An Act to Promote the Public Health Through Workplace Safety for Social Workers, H3864.” The act requires employers of social workers to create safety plans for their workplaces as well as perform annual risk assessments relative to risk factors of workplace assault (NASW, 2014). However, in order for agencies to develop risk assessments and safety plans, information must be gathered from the therapists who are working in the field. Plans must be evidence based; plans must be based on therapist experience, including environmental factors, social and economic factors, and context based, stemming far from literature informed recommendations.

The NASW (2013) proposes that clinicians should assess and take appropriate steps prior to conducting a home visit, such as completing a risk assessment prior to each visit. A risk assessment includes a review of the following: environmental factors, clients living space, proposed work activities, increased risk due to clients condition, worker vulnerability, condition of emergency, and mutual safety discussion planning with the client.  Despite utilizing this safety risk assessment instrument, the safety concerns remain. Many guidelines of the risk assessment seem nearly impossible to adhere to.  The NASW (2013) risk assessment asks: “Have any events occurred in the neighborhood within the last 48 hours that might increase risk (for example, homicides, abductions, robberies, drug raids)?” Hence, social workers work in high crime areas where events increasing risk occur everyday. NASW asserts “While even the most comprehensive and detailed safety policies cannot assure safety at all times for all parties, the conscientious use of safety policies underscores the importance of safety to staff, clients, administration, and governing boards. Raising awareness about safety can create a level of preparedness that helps build an agency climate of safety” (NASW, 2013).

When providing in home therapy services for child maltreatment cases, the most important factor is assessing the living environment.  Traumatic events that occur in childhood can be psychologically overwhelming and threatening to a child’s sense of security and safety, potentially leading to subjective feelings of fear, shame, helplessness, anger, and worthlessness (Cohen, Mannarino, & Deblinger, 2012). The Child Physical and Sexual Abuse: Guidelines for Treatment (2004) report says that “Since many abused children continue to live with the caregivers or siblings who have hurt them…this focus on safety is a priority” (p.24).  An evaluation of risk during the initial assessment helps to identify what contextual treatment interventions are necessary, so “therefore, understanding the level of risk for harm in the child’s environment and subsequent safety planning are the first steps in assessment in abuse cases” (p.24).  Therapy can be counterproductive when children exhibit posttraumatic stress disorder symptoms while still living in fear producing environments and situations.  According to the guidelines for treatment, recommendations include that “Treatment of fear and anxiety symptoms likely will be fruitless or even harmful because it would be appropriate for a child to continue to be afraid and vigilant in such a situation.  If treatment continues, children may be desensitized to real danger cues, placing them at greater risk in the future.  Therefore, evaluation of environmental and contextual risk and safety is a unique and critical part of the assessment process in abuse cases” (p.24). Ellen and Turner argue that  “As children get older, living in a neighborhood where crime is commonplace may lead them to believe that it is acceptable, or even ‘normal’” (p. 841). Consequently, a worker’s safety can be compromised given their clients acceptability to their unsafe environment.

Unlike the home environments therapists go into, traditional office and agency environments often actively promote safe practices. Common practices include: working environments that allow clinicians to easily exit in an unsafe situation, access to an alarm system, restricted access to potential objects that may be used in a harmful way, (for example, scissors, stapler, office decor) secured entrances, presence of a supervisor or additional staff when meeting with a client with safety concerns, well-lit hallways and space, and secured telephone lines in case of an emergency.  I understand I have the right to advocate for safe working conditions; however, personal safety is not always predictable, especially in the home and community setting.

In home therapy does not offer a predictable setting like most traditional in clinic office spaces. Therapy in the home can occur in the bedroom, bathroom, kitchen, living room, attic, porch, backyard, car, driveway, nearby park, school, library, or local coffee shop.  Simply identifying an appropriate treatment area can be challenging; the clinician must keep in mind if the identified space is safe, appropriate, healthy for the relationship, productive, and ethical. Consequently, assessing whether a space is considered appropriate or safe without being judgmental, disrespectful, or discriminatory, is difficult.

Ensuring safety is complicated with in-home therapy without an established working alliance or the ability to manage feelings and counter-transference reactions when faced with problem saturated clients, families, and communities. Everyday, clinicians face the on-going difficulties of managing countertransference and the barriers to forming alliances in the context of in-home treatment. Establishing a working alliance is challenging when countertransference is complicated by safety, race, class, and poverty.  I argue that worker safety is partly produced by the effectiveness and degree of the working alliance.  In the absence of a working alliance it is hard to imagine clinician safety, yet, it is also impossible to imagine that an alliance is possible when intense emotions are experienced in the presence of child sexual abuse. Reynolds-Mejia & Levitan (1990) state, “Therapists no less than other human beings tend often to impose upon the family their own expectations regarding how the family should react, feel, and process their trauma. In a therapeutic setting, however, the expectations may subvert the healing process” (p. 59).   The problem of countertransference, worker safety, and establishment of a working alliance, is intensified in the in-home setting.  

The working alliance is a concept that can not be ignored to promote safety within the in-home therapy context. Without a working alliance, safety seems impossible. Many terms have been used to describe the client and therapist bond: therapeutic alliance, therapeutic relationship, and the working alliance. Beginning with the term therapeutic alliance, a long accepted construct, it has operationalized in many ways. The working alliance, a construct that characterizes the therapeutic relationship (Barley & Lambert, 2002), has been more broadly defined as collaboration between the therapeutic participants to facilitate healing (Bachelor & Horvath, 1999). Hence, healing is hindered in the absence of a working alliance, therefore, compromising the development of a therapeutic bond. In an effort to minimize Becky’s family’s  defensive outlook on treatment, developing a working alliance is crucial. Yet, collaboration, developing a mutual understanding with each other, and building trust and communication seems almost impossible when safety issues impede. Effective communication, in part, is grounded in the skills of listening and responding and vital to the working alliance.  Hence, recognizing and respecting differences in client race, values, culture, gender, and social attributes also foster communication.

Despite the working alliance enhancing safety for in-home therapists, countertransference, can affect the formation of this alliance creating additional barriers with ensuring safety. Freud’s term, countertransference, refers to the analyst’s unconscious and defensive reactions to the patient’s transference.  Subsequently, broader definitions of countertransference developed to include all emotional responses of the therapist to the client, rather than merely those pathological distortions by the therapist resulting from his or her own unresolved historical issues (Reynolds-Mejia & Levitan, 1990).  In the treatment of child sexual abuse, it is almost impossible to not feel strong emotions. In particular, in the in-home setting, these intense feelings can destroy any prospect of achieving a therapeutic process and countertransference issues play a prominent role (Reynolds-Mejia & Levitan, 1990).  Reynolds-Mejia & Levitan write, “The governing theme of these reflections is that countertransference reactions will always weave a spell upon therapists’ emotions, and thus always present a danger of superseding the professional’s therapeutic agenda” (p. 61).

Countertransference can hinder growth, resulting in barriers of establishing a therapeutic relationship and a sense of safety. Hence, at the same time, “this introjected client material is an invaluable tool and resource that is available to the therapist who is aware of and able to accept and manage countertransference reactions” (p. 61).

Clinicians who do not feel safe potentially place themselves at risk for experiencing negative emotional reactions as part of a countertransference experience. Reynolds-Mejia & Levitan (1990) assert a clinician’s capacity for empathic tolerance is challenged by in home treatment, and “the risk of spontaneous acting out of countertransference is proportionately increased by the additional immediate stimuli, the lack of familiar and protective surroundings, and increased opportunities for the family to test the therapist’s boundaries and adaptive resources” (p.57). As Reynolds-Mejia & Levitan cite, “The in-home setting poses greater threats to the therapist’s sense of control, competence, and personal and professional adequacy, thereby compounding the therapist’s anxiety” (p. 57). Despite these threats, in the case of a sexually abused child, the therapist must process their feelings and reactions while simultaneously acting as a healing agent.

The Case of Becky

(Warning: This case material contains a disclosure that may be difficult to read.)

Becky’s case, a referral from her middle school counselor, reported Becky exhibiting sexualized behaviors in the school environment, as well as a long history of maltreatment allegations by her parents.  He reported Becky sought attention from her peers, as well as her teachers, through use of sexual language, drawing and writing sexual explicit pictures and stories, and frequently exposing her body inappropriately.  Her counselor reported that on two occasions, rumors were spread about Becky being caught in the boys bathroom performing oral sex.  Becky denied these allegations.  Another report involved Becky writing a story about a sexual fantasy with her male gym teacher.  The counselor reported numerous attempts to meet with Becky’s parents about her sexualized behaviors with no contact ever being made.

Becky had a long history of trauma. At age 7, Becky was placed in foster care and separated from her sibling, following her parents 6 months incarceration for drug charges.  After 15 months, Becky was reunited with her mother, father, and 10 year old sister Julisa.  From the age of birth, Becky was exposed to on-going domestic disputes between her parents, gang retaliations, substance abuse, and multiple exposures to crime in her neighborhood.  Becky’s family had a long history with social services for alleged child maltreatment.  Despite Becky’s trauma history, Becky had no prior history of receiving mental health services.  

“As you can see, I don’t live in a safe neighborhood.”  Becky pointed to a wall filled with R.I.P. memorial picture frames.  “Yesterday, another cousin–Macho–was shot down.  Police blocked off my street, and people weren’t allowed to leave their houses.  Macho’s mom screamed the entire time.  They made her stand behind the yellow tape.  It was sad, but my dad said that whoever did this is going to regret it.  I wonder who will be next.”   Becky’s high risk, unsafe, violent, police involved neighborhood was her normal.  Her descriptions of normal went against everything I was ever taught, thought, or experienced.  

Becky’s father, Luis, had been diagnosed with bipolar disorder and PTSD.  He had been in an out of jail since he was fourteen and had a long history of trauma.  Both his brother and his father had been brutally murdered right in front of him.  Luis was placed in foster care, but his real family had always been his gang.  He was an alcoholic and daily street drug user, and during home visits, his behavior was erratic.  Luis had teardrops tattooed near his eyes and “FUCK YOU” inked into his knuckles.  During more than one treatment session, he was incoherent, but Becky and I continued therapy through his moans, grunts, and random screams.  Usually, he paced around the home, frequently entering the room, and walking right back out without saying a word.  It felt like surveillance, and I couldn’t imagine how Becky could ever feel any sort of safety with him around.  I certainly felt at risk.  I tried to work out a plan with Becky’s mother so that she could call me to cancel if Luis was unstable, but it was clear early on in treatment that she was helpless.  Becky’s mom had a history of sexual abuse.  As a result, she turned to drugs and prostitution at 14 years old.  That’s when she had met Becky’s father, who was ten years older and a well-respected gang member.  She told me, “Luis took me in.  He offered to take care of me.”  I blinked at her in disbelief, but she did not flinch, not even as gun shots rattled in the near distance.

Many factors challenged ensuring safety, especially development of a working alliance in Becky’s home. Language barriers presented safety concerns and challenges with establishing a working alliance. As an English speaking clinician, I am not able to understand Spanish- the language the family was fluent in. Safety concerns arose one session when I was not able to understand what was being said, creating discomfort and unpredictability. Becky’s mother and father began to speak in Spanish. Their tone of voice increased and Becky’s father was becoming visibly angry.  (In-spanish) “If this lady don’t leave my house she’s gonna wish she did, this gun is loaded and I’m not scared to use it”.  Becky informed me: “Dad says he thinks you should leave now, because he doesn’t agree with you and is getting angry”.  Becky later informed me in a session what her dad had really said the day I was asked to leave.  She reported that her mother was trying to calm him down, but it doesn’t always work.

Home visits present many safety complexities with confidentiality. It is common that neighborhoods and communities look out for one another. Often, while walking to Becky’s house, I was approached by neighbors inquiring about my presence at the house. In an effort to protect the families confidentiality, I am ethically obligated to not identify the family who I am working with. Because of this obligation, I often feel threatened by the inability to express my presence and who I am working with when I am asked by a group of gang members who are protecting their turf. Ignoring or informing the group that it is confidential information can lead to retaliation, safety concerns, and leaves me feeling insecure upon each arrival to the home. Becky’s father viewed his neighborhood as part of his family, everyone looked out for each other. With no working alliance established with Becky’s father, it was hard to imagine protection from the angry community members that seen me as a threat. I wasn’t safe in Becky’s home nor the neighborhood surrounding me should I need help. This was a scary feeling.

Frequently, confidentiality and safety issues occurred when sessions were interrupted by Becky’s friends, extended family members, or neighbors. Becky’s family had minimal boundaries and they were unable to recognize the inappropriateness of neighbors or family members intrusively entering into our therapy session. I cannot always predict or control who may be part of the therapy sessions. It was not an option to consider Becky’s family members safe because she did, nor did I have the ability to determine their risk factors or take safety precautions. It seems impossible to avoid the unavoidable of predicting who will enter a session while I am in Becky’s home.

Throughout the course of our sessions, safety concerns were apparent. My mind was preoccupied with how to manage my safety.  When Becky wanted to sit outside for privacy, I feared crossfire.  When we were inside and she locked the door–mostly because neighbors and family members often entered our therapy sessions–I worried about how I could exit quickly in an emergency.  Becky wanted us to meet in her attic, and I felt guilty telling her that her “safe space” was scary to me.  We ended up meeting in the bathroom.

“My dad told me to keep my mouth shut or there would be big problems for me and you, and you know how my dad is.”  Twelve year old Becky had the inclination to protect me.  “I’m going to tell you anyways.”  Her hands were shaking, and the fear in her eyes made my stomach turn.  I couldn’t deny her.  Suddenly I heard her father come home.  “That lady is here again?  if she doesn’t leave my house she’s gonna wish she did.”  Despite the yelling beyond the door, Becky and I hunkered down in the sweltering room. Unable to speak,  I handed her a pen and a pad, and Becky sobbed as she began to write the horrific details of the night before.

Last night, I tried to run away. My uncle and father did those really bad things to me again. But this time, it happened to my younger sister, too. I screamed as loud as I could, but no one helped me.  First, my father told me to go downstairs in the basement because he needed to talk to me. My uncle is always the first one to come down. I watched in fear as my uncle opened the door. I knew exactly what was going to happen. He told me to take off my clothes and sit on the couch. He always tells me that if I don’t do exactly what he tells me, than when my father comes, I will pay. My uncle covers my mouth when I scream, but only when he has sex the normal way with me. When he’s going to have sex with me in my butt, he puts a long sock in my mouth because it really hurts, and I scream loud. Last night I had to pay for being disobedient. I told mom, but she told me there was nothing she could do. I hate when my dad urinates on my face. I don’t know what is worse, the sex or pee. Mom makes me clean up the pee after, and dad and my uncle laugh about it.

I immediately began safety planning with Becky. I informed her that I was going to leave her house, go to my car, and call child welfare services. I wanted to take Becky with me. I informed her that I would come right back in and stay with her. Becky made me promise I was not leaving her. I told Becky not to say anything to her parents. I told her to make pretend everything was fine and that she did not need to tell them that she disclosed the situation to me.

Walking down Becky’s attic stairs is a memory I cannot forget: the fear and anxiety as I smiled at the uncle and father and said, “I’ll be right back, I have to get something in my car”.  I felt trapped. Internally I froze; externally, I wanted to scream and cry and tell the adults what disgusting human beings they were. I called child welfare services and an emergency response team was on their way. Once child welfare workers arrived, I walked back in the house with them. I had made a promise to Becky.

I was not prepared for what happened next. As I went back upstairs to the attic, Becky informed me that she told her mom that she told me what had happened. Becky told me that her mother was very angry and told her that everyone was going to go to jail because of her. Becky cried as she pleaded for me not to tell anyone what she disclosed. I felt angry. How could a mother react this way? I wanted Becky’s mother to be supportive, angry at the adults who hurt her, and to protect her daughters. When the child welfare workers questioned Becky, Becky refused to speak. She told the workers nothing had happened.Becky’s mom reported to the workers that Becky attempted to run away last night, and this was her way of trying to get removed from the home. She insisted that Becky was making up lies and stories. Becky’s dad told the workers how much he loved and cared about Becky.

The response team looked at me and said, “There’s nothing we can do. Becky says nothing happened, and she’s not talking.”  Strong countertransference feelings arouse- I needed to rescue Becky, I had to defend her, and she wanted this too.  Furiously, I plead my case. I begged for child welfare services to remove the children. I requested that I be present for support to empower Becky to at minimum disclose sexual abuse via her father and uncle. I began by telling Becky she was strong, I was here to support her, and she was going to be kept safe. Once feeling safe, Becky disclosed the abuse. I informed the workers that the local police needed to be called to be present during the removal process. After all, I knew Becky’s family history, the risk factors, and the potential safety risks that could occur during the removal process.

As the police arrived at the home, the adults in the home become angry and threatening. Becky’s father began making verbal threats and aggressive gestures. He shouted to the police that I was a baby snatcher, full of lies, and that I was going to pay for this. As the children were removed, Becky’s father began destroying the home property. I ducked and shielded myself as objects were thrown. While the police attempted to calm him down, Becky’s uncle ran from the home, and has been missing since. Becky was successfully removed from the home, temporarily, pending an investigation.

One week later, I received a threatening voicemail on my office phone. The voice was disguised: “You will pay for this, I am coming after you, watch out”! Flooded with emotions, I immediately assumed it was Becky’s father.  Indeed, he knew the vehicle I drove, the agency I worked at, and most concerning, we lived in the same community.  The fear I once held, feeling unsafe while working in the home or environment of a client, now progressed into my personal life.  Feeling unsafe is now “my normal”. The constant stress associated with personal safety effects my mind, body, emotions, and behaviors. I struggle to maintain my outer mask, my societal face, that is acceptable to the clients I am serving while in their environment- and now, in my personal life, in my environment. My outer mask attempts to react “normally” to the high risk environment I am in, regardless of how I am feeling internally. Mentally, emotionally, and physically, I feel unsafe, unprotected, and at risk.

Discussion

Clinical services provided in Becky’s home and community setting had become increasingly unsafe and unpredictable. Safety limitations contributed to difficulties with managing countertransference. Reynolds-Mejia & Levitan (1990) write, “It is important for each therapist to be aware of countertransference symptoms as cues to examine more closely the therapist’s inner reactions, and the struggle to process them” (p.61). Pretending to feel comfortable or safe is difficult, Becky’s family was sensitive to the vibes I conveyed.  On one occasion, Becky’s mother asked me if I was worried about my vehicle parked outside.  Boyd-Franklin and Bry assert “Some clients may be offended if they feel clinicians are overly fearful about entering their communities”  (p.55). As I nodded no, I questioned myself as I watched the three male teenagers surround my vehicle pointing at my expensive wheels.  On another occasion, I asked Becky’s mother if she would mind seeing me out on one late evening.  Unable to do so, she questioned if I was scared since she lived in such a bad neighborhood. She reassured my safety as I walked to my car. Adhering to NASW recommended safety guidelines seemed impossible, I was forced to walk alone to my car, despite my reservations of feeling unsafe.

Implementing safety guidelines while working with families in the home and community settings can be quite different than office based in clinic work. While traditional boundaries and professional rules adhere mostly to in clinic work, clinicians still need guidelines to assist with the everyday challenges we face within the home setting when experiencing safety dilemmas. In home clinicians need more flexible definitions of boundaries and professional rules that addresses these dilemmas we face on a daily basis. Entering into our client’s home, we must remember we are in their home, and we have to respect their home, opposed to the family entering our office, in which they must adhere to the office rules and respect the office space. Boyd-Franklin and Bry (2000) recommend clinicians “go with the flow” when conducting therapy in the home, in particular for the first session. “Do not be in a hurry on a first visit to impose rules or your own sense of order. Try to relax, fit in, and get to know all of those present” (p.39). Although challenging,  I often went with “the flow” while conducting home visits at Becky’s. The home environment was chaotic, unorderly, and our sessions were difficult to structure. Countertransference was not always problematic, however the importance of managing problematic countertransference was crucial. In an effort not to hinder the therapeutic relationship, many times I refrained from voicing my own disbelief of how this family could engage in therapy with any expectation of progress in such a chaotic environment. During treatment, Becky’s father often went to his room and turned up his music to display his anger. The vibration went through my body and I could not concentrate, respond or listen effectively, or hide my anger. I informed Becky I could not engage in therapy during these circumstances, and not recognizing countertransference, added in that nor should she. Becky replied “ You’ll get used to it”. Becky was desperate for our relationship to blossom and nothing was going to get in the way.

Addressing safety concerns with a family before establishing a therapeutic relationship can hinder continued treatment if as a result the client now feels threatened, insulted or disrespected. Setting safety preventives, boundaries and rules for therapy services when delivery is conducted in a client’s home is challenging to say the least. Who am I – a visitor- to set rules in their home? How do I balance respecting their home/rules and encourage the same respect for my preferences?  During home based sessions, it is not unlikely for the family to be guarded and uncomfortable as their home environment offers added insight to their life. I am exposed to their reality: open door policy-frequent visitors in and out of home, drug dealing and drug use, domestic disputes, poor supervision of children in home, and exposure of unhealthy family relationships. Establishing a working alliance seemed unimaginable. Boyd-Franklin, Cleek, Wofsy, & Mundy, (2013) describe many real world realities when conducting therapy in the home with families that are mandated to participate in treatment; some of their recommendations include: use of self in the process of joining and establishing therapeutic rapport, incorporating culture considerations, establishing family connections, and incorporating different family systems model techniques.

Becky’s father Luis was certainly distrustful of me, affecting the working alliance.  It was clear, Luis’s involvement was necessary, however, almost impossible.  Boyd-Franklin and Bry propose a framework to help guide clinicians facing “healthy cultural suspicion” (p.13), asserting that home based therapists must be aware of this perspective.  They recommend that clinicians be prepared for it and “must be able to reframe it as an attempt by the family to protect its boundaries” (p.13).  While I recognized that Becky’s father’s statements could stem from healthy cultural suspicion, I was cognizant to not be dismissive of my own countertransference. We both recognized each other’s power held in our positions. He was fearful of me,  as I was seen as a threat to him and his family, a mandated reporter, a snitch, and a untrusted intruder. Likewise, I was fearful of him, as I saw him as powerful, untrustworthy, dangerous,  and a risk to my safety.

Reynolds-Mejia & Levitan (1990) assert “It should be clear that the therapist must continually question and monitor both internal and external reactions to the client family. This process is particularly critical in in-home work because the professional is called upon to react spontaneously and without environmental supports and protection” (p.60).

Much literature on treating trauma and sexually abused children emphasis being fully present in the moment with the client which helps to create a safe environment. As a practicing clinician, I know that for therapy to be as successful as possible, it is crucial that the client feel they are safe; whether it be a physical or mental state. However, just as it is important for the client to feel safe in therapy, I argue that it is just as important for the therapist to feel mentally and physically safe. Becky’s case illustrated the many safety concerns that left me as the therapist feeling foremost, unsafe, insecure, and uncomfortable; therefore, compromising treatment.

Arming the alarm system, eyeing the safe that holds my firearm, deadbolt locks, secured entrances, lights activated by motion, and the assurance of knowing I live in a safe distinguished neighborhood- these are just a few of the factors that drive my perception of safety. My sense of safety, while at home, affects my psychological state. I feel secure, safe, certain, and foremost, comfortable. I know that I have a safety plan in place, should I feel my safety being compromised.  I know that when I feel threatened, I have increased levels of anxiety, low levels of self-confidence, and independence no longer exists. As I prepare to enter my vehicle to leave my home- my safe place, I realize this psychological state of feeling safe and secure, to be temporary. As a session begins, I know that my psychological state has a profound impact on my ability to function in a therapy session- cognition, speech, thoughts, behavior, mood and affect, perception, and insight.

The concept of safety for clinicians working with children expands beyond what historically we are used to: free from neglect and emotional, physical, and sexual abuse. But, where does psychological safety fit it; the concept of feeling safe? For children to grow and develop; children need to feel safe. From an early age, we all need something that helps us feel safe. For children this might be a blanket, a stuffed animal, a smile, or a loving caregiver. As we get older, safety continues to be sought; perhaps though a significant other, a spiritual belief, food, or our home.

I knew, clinically, that therapy was to be at Becky’s pace, not my own; it was important to allow Becky to respond to the therapy before moving on. However, safety concerns almost always compromised treatment. During my sessions with Becky, I felt that the burden of safety lay within me, as the therapist. I was to make sure Becky was safe in order for progress to be made. Developing a sense of safety is intuitively necessary; we not only need to feel safe, but like to, and seek this feeling of safety. During Becky’s disclosure of sexual abuse, the lack of safety I felt, manifested itself in the form of anxiety, disturbing my ability to concentrate and think effectively. I was no longer attuned to my client; hence attunement in therapy is a crucial skill. Despite once being attuned to Becky’s interpersonal enactments of her trauma as it emerged in therapy, this was no longer the case.  My ability to be attuned during this intense moment in therapy while feeling unsafe hindered my reactions, even more so, my interventions with my client. One could say that the therapist’s attunement with their client, is a building block for a therapeutic relationship, a connection, establishment of a sense of safety. The foundation of safety, I once created with Becky during our therapeutic relationship, was no longer there, hindering her ability to experience emotional risks she was once able to.

In an effort to prevent psychological stressors in the environment from hindering my sense of safety, I strived to foster a sense of safety for myself, for Becky. But, as my emotions became overwhelming, I felt my internal world spiraling out of control, and therefore, feeling unsafe. It was no longer safe for me to express my emotional self and think rationally; internally and externally, I was no longer safe. Hence, Reynolds-Mejia & Levitan (1990) assert, “The timely and regular sharing of countertransference material, at a therapeutic level, is the most powerful force for change the therapist can offer” (p.61).  Without a working alliance or feeling safe, sharing of countertransference material was unimaginable.

As Becky frequently spoke about her neighborhood police involvement, robberies, drug raids, domestic disputes, gang violence, and homicides, I knew being aware of my surroundings while going to her home is vital. Her housing unit, centered in the middle of a neighborhood that posed high safety risks, was a neighborhood I was used to going, too. Inside Becky’s poor lit home, I held constant awareness of the families weapons they spoke about for protection. With my eyes frequently focused on the large knife hanging from the wall, I was aware of the many visitors who entered the home- many of whom were affiliated with the neighborhood gang. The exit was not merely accessible with the six bolt locks, and I often pondered how to disclose unwelcoming information, particular with Becky’s father’s untreated mental illness and a history of violence and threatening behavior. On one dark rainy night, while parking my brand new BMW, I felt aware of my worker vulnerabilities- young, caucasian, female, alone, wearing a button down coat, and exposing my work I.D. It is not uncommon that I presented with fear and ambivalence in my eyes- while attempting to ignore the drug transaction occurring in front of me. Despite this encounter, I was fully aware that Becky’s home visit always presented with safety risks and constant on-going risk assessments were conducted. Aware that I am seen as a snitch, I quickly walked by the drug transaction, pretending a smile, while attempting to remember their faces in case retaliation or intimidation later occurred. After all, it is my obligation to provide this family with the services they need, despite my reservations.

My treatment with Becky continued 16 months after her sexual abuse disclosure.  I met with Becky weekly at her foster care placement.  During this time, Becky had weekly supervised visits with her parents.  Much of our therapy consisted of safety planning, mainly because I was aware the plan was for her to return home- this scared me.  Throughout our treatment together, Becky constantly worried about returning home.  She cried and begged for me to not send her back home.  She wrote me letters begging for me to adopt her, pleading she would be the best daughter ever. Reynolds-Mejia & Levitan (1990) assert “Empathic tolerance is always at risk in sexual abuse treatment, as therapists struggle to provide healing while protecting themselves from feeling fully the client’s’ trauma and damage” (p.59). Becky’s cries for help,  kept me awake at night. Becky was reunited with her parents.  Her father was found not guilty, and both parents completed the required parenting classes necessary to regain custody.  Becky asked why I was not going to be her therapist anymore when we said our final goodbyes. Telling the truth seemed impossible. Was I really supposed to tell her that I did not feel safe returning to her home to provide services, that without a working alliance, I was fearful of retaliation for being the “child snatcher”, that countertransference reactions presented a danger to the treatment process?  After my final session with Becky, I was not the same. I felt as if I failed- failed to keep her safe. More so,  I could no longer protect her and keep her safe. Who was going to keep her safe now?

  Conclusion

Despite the National Association of Social Workers (2013) providing a framework to enhance clinicians safety with their development of guidelines, home based therapy is increasingly growing, and there is much to learn about risk assessments and guidelines to be developed that speak to the safety concerns of home-based therapy clinicians. As mentioned by NASW, “A major tenet of the National Association of Social Workers’ (NASW) threefold mission is to promote, develop, and protect the practice of social work and social workers. In alignment with that mission, NASW establishes professional standards and guidelines to support quality social work practice” (NASW, 2013).  Despite clinicians adhering to universal safety guidelines, countertransference reactions, and working alliance importance need to be brought to attention, and integrated into the daily home visits to promote safety.

Assessing risk and paying full attention to your personal safety requires the skill of multitasking. When providing in home treatment, there is no such thing as multitasking. It is impossible to give a client your undivided attention and listen attentively, while simultaneously giving your personal safety full attention. Providing clinical therapy, while recognizing countertransference reactions, such as  your mind and body in full stress reaction mode imposes on effective delivery of therapeutic services. Despite safety guidelines and safety protocols in place, not all threats to safety can be anticipated or avoided.

Becky’s case demonstrated the barriers of developing a working alliance in the context of feeling unsafe as a clinician. A working alliance requires feeling safe, hence, feeling safe requires a working alliance. Managing countertransference reactions in a high risk, unsafe, unpredictable environment is difficult when feeling inadequate, at risk, and with an inability to think.  The threat of being kicked out of a home or feeling cautious to not escalate a family member while trapped in their space, blurs feeling grounded, competent, and safe.  Similar to Becky, I question if feeling unsafe is my new normal


References

Ackerman, S., & Hilsenroth, M. (2003). A review of therapist characteristics and techniques

positively impacting the therapeutic alliance. Clinical Psychology Review, 23, 1-33. doi:10.1016/S0272-7358(02)00146-0

Bachelor, A., & Horvath, A. (1999). The therapeutic relationship. In: Duncan, B.L., ed. The heart

and soul of change: What works in therapy.Washington, DC: American

Psychological Association, pp. 133–178.

Barley, D., & Lambert, M. (2002). Research summary on the therapeutic relationship and

psychotherapy outcome. In J. C.Norcross ( Ed.), Psychotherapy relationships that work:

Therapist contributions and responsiveness to patients (pp. 17– 36). New York, NY:

Oxford University Press.

Berliner, L., Hanson, R., & Saunders, B. (Eds.). (2004). Child Physical and Sexual

Abuse: Guidelines for Treatment (Revised Report: April 26, 2004). Charleston, SC: National Crime Victims Research and Treatment Center.

Bordin, E. S. ( 1979). The generalizability of the psychoanalytic concept of the working alliance.

Psychotherapy: Theory, Research & Practice, 16, 252– 260. doi: 10.1037/h0085885

Boyd-Franklin, N. & Bry, B. H. (2000). Reaching out in family therapy: Home-based, school,and community interventions. New York: The Guilford Press.

Boyd-Franklin, N., Cleek, E., Wofsy, M., & Mundy, B. (2013). Therapy in the Real World:

Effective Treatments for Challenging Problems. New York: The Guilford Press.

Cohen, J., Mannarino, A., & Deblinger, E. (2006). Treating Trauma and Traumatic Grief

in Children and Adolescents. New York: The Guilford Press.

Ellen, I., & Turner, M. (1997). Does Neighborhood Matter? Assessing Recent

Evidence. Fannie Mae Foundation, 8(4), 833-866.

Retrieved 1/10/2015 from http://www.centerforurbanstudies.com/documents/electronic_library/neigh

borhoods/does_neighborhood_matter.pdf

Freud, S. (1913). On beginning the treatment. In J. Strachey (Ed. and Trans.), The standard

edition of the complete psychological works of Sigmund Freud, vol. 12 (pp. 112–144).

London: Hogarth Press (original work published 1913).

(2013). Guidelines For Social Worker Safety. National Association of Social Workers. Retrieved

01/15/2015 from

https://www.socialworkers.org/practice/naswstandards/safetystandards2013.pdf

Kelly, J. (2010). NASW  NEWS. The urgency of social worker safety. Retrieved 07/04/2015

           from http://www.socialworkers.org/pubs/news/2010/10/social-worker-safety.asp

(2014). NASW Massachusetts Chapter. Work place safety. Retrieved 07/04/2015 from

http://www.naswma.org/?page=SafetyPolicyRecs#PolicyRec1

Reynolds-Mejia, P., & Levitan, S. (1990). Countertransference issues in the in-home treatment of

child sexual abuse. Child Welfare, 69(1), 53-61.

Ringstad, R. (2005) Conflict in the Workplace: Social workers as victims and perpetrators.    

           Social Work, 50, 305-313  

Tufekcioglu, S., & Muran, J. C. (2015). Case Formulation and the Therapeutic Relationship: The

Role of Therapist Self-Reflection and Self-Revelation. Journal Of Clinical Psychology,

71(5), 469-477. doi:10.1002/jclp.22183

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