Salvaging Clinical Connection following Child Abuse Reporting

1. Salvaging Clinical Connectionfollowing Child Abuse Reporting October 23, 2013 City of Fremont Youth & Family Services (YFS) Helen H. Hsu, Psy.D.

2. Introductions What type of clinical populations and settings are you currently working with? Who here has made CPS (or APS) reports? (ever? recently?)

3. Inspiration • Every licensed therapist takes the day long required Child Abuse Reporting workshop. • When do we ever get to talk about the work that happens AFTER the report(s)?

4. Objectives • Overview of history & review of mandated reporting • Identify key aspects damaged in clinical relationship • Review approaches to re-engage families • Integrate cultural competency • Understand factors for sound decision processes following abuse reporting • Examine case material with colleagues to practice clinical connection repair-planning.

5. Pop Quiz! Please take a few minutes to respond to items on the Child Abuse overview quiz.

6. Answer each question: Studies show, in the USA, there are how many adult survivors of child sexual abuse? At which age are children most victimized? What is the most common type of child abuse reported? Which type of child is most targeted by child molesters? Approximately how many children are found to be substantiated victims of neglect or abuse per year in the USA? Professionals make what percentage of alleged abuse/neglect reports?

7. A Brief History of Child Abuse Reporting in the USA • In 1866 Massachusetts passed a law authorizing judges to intervene in a family when: • “by reason of orphanage or of the neglect, crime, drunkenness, or other vice of parents’ a child was ‘growing up without education or salutary control, and in circumstances exposing said child to an idle and dissolute life.’” • As early as 1942 Massachusetts had a law authorizing magistrates to remove children from parents who did not “train up” their children properly

8. A Brief History of Child Abuse Reporting in the USA: The landmark case (1874) • Religious worker Etta Wheeler was notified by neighbors about 9 year old Mary Ellen Wilson who was being beaten & neglected in New York City’s Hell’s Kitchen. • Mary Ellen wore insufficient clothing for the cold winter, was beaten, cut with scissors, malnourished, isolated, confined, and berated by her foster parents. • Police declined to intervene. • Charities had no authorization to help. • There were no juvenile courts or child protection services in existence

9. A Brief History of Child Abuse reporting in the USA • Wheeler sought advice from Henry Bergh, founder of the American Society for the Prevention of Cruelty to Animals (SPCA) • Elbridge Gerry found a legal means to rescue Mary & garnered media coverage. • In 1875 the first U.S. organization devoted entirely to child protection was established:The New York Society for the Prevention of Cruelty to Children.

10. The evolution of child abuse as a societal and community concern • As news of NYSPCC spread, eventually 300 SPCC’s were organized nationwide • 1962 publication of blockbuster article The Battered Child Syndrome by pediatrician Henry Kemps and colleagues. Kemps played a leading role to bring child abuse to national attention widespread attention in the 1960’s and 1970’s • As of 1965 California still had no county system of child protection • Public, political and research awareness exploded in the 1970’s. By 1967 ALL states had reporting laws • By 1980’s the Child Protective System was deluged

11. Scope of the problem • Child Welfare Dynamic Report (CA Dept of Social Services and UC Berkeley, 2010): • 87,000 children • 62% neglect • 19% physical abuse • 9% sexual abuse • 10% emotional abuse Studies vary- but a moderate estimate is that 36% of children in a community based clinic setting have been abused.

12. Overview of Reporting Neglect: failure of guardian to provide for child’s basic needs (food, shelter, medical,emotional,education) Physical abuse: nonaccidental physical injuries to child inflicted by caregiver or other party (hit,burn,cut,bite,stab, shake) Sexual abuse: activities that engage child in sexually explicit conduct or simulation(pornography, molest, incest, rape, exploitation) Emotional abuse: pattern of behaviors that impair child’s emotional development and self worth.

13. Who reports? • Psychologist, physician, surgeon, intern, EMT, licensed nurse, MFT and trainee, social workers and trainee, psychological assistants • school principal, teacher, coach, classroom aide, school employees and volunteers • dentist, hygienist, optometrist,, podiatrist, chiropractor • police and fire personnel • public assistance worker • clergy • animal control officers • commercial film processing staff • DA investigator • child visitation monitors • medical examiner and coroner • daycamp or daycare staff and supervisors • probation officers and staff

14. Let’s be real: barriers to reporting • Feeling unsure about the facts • Uncooperative or unavailable child and/or family members • Unavailable or unhelpful family service staff or police • Nervous about legal matters • Concerns that nothing will happen - except now the family abandons treatment • Worried that being “in the system” may be worse than the current situation • Children commonly rescind statements

15. To tell or not to tell...the client? Clinical Considerations Does your workplace have a policy about this? Do you have reliable colleagues or supervisors for prompt consult? Have you had experience with this? What is your understanding of the safety of child/family situation?

16. Examples...should the clinician tell? Social worker Rigo works with Tom and Iris, a homeless couple who are living in a motel. Both suffer from severe mood and substance abuse disorders. Rigo made a CFS report due to concerns about their ability to safely care for their 8 month old son. The next day the couple call Rigo, “Oh NO! Rigo, you have to help us! Some *&%# called CPS and they took the baby!” Rigo can hear them weeping and screaming blame at one another. Therapist Julie is in session with 14 year old Hannah who reveals that she was “locked out of the house and hungry” last night when her parents got angry at her. She then shares an audio recording of her parents screaming insults and awful threats at her. Julie feels this is reportable. The parents are waiting outside in the lobby of the clinic right now.

17. After the Report-Now what? • Report will be screened and Categorized: • substantiated • unsubstantiated • no finding • alternative response • intentionally false • unknown. • Caseworker may: • interview victim • visit home • voluntary service may be provided • child may be removed • case may be closed

18. After the Report Family Maintenance example: children stay in the home and supportive services are provided such as social worker visits, mandated or recommended mental health treatment Family Reunification example:children have been removed from custody, supervised visitation may take place while the guardians take steps to regain custody such as drug rehabilitation treatment, parenting classes

19. What’s our goal? U.S. Administration of Health & Human Services “Preferred outcome after child maltreatment/sexual abuse is that after intervention the family will be intact”

20. Salvaging The Clinical Relationship • CLIENT REACTIONS • betrayal • fear • criticism • blame/blamed • persecuted • shame • anger • despair • failure • THERAPIST CONCERNS • guilt • anger (self) • anger (clients) • danger “lashing out” • responsibility for family • self righteousness • anger • despair • failure

21. Salvaging the Clinical Relationship The First Re-frame: A sentinel event report does not equal failure! The Second Re-frame: don’t despair, there is hope & opportunity and we will make an action plan

22. Anger • Identify underlying emotions • Acknowledge difficulties and challenges • Enhance skills to reduce catastrophizing • Re-direct energy to solving problems • Find strengths

23. Unraveling the Blame Game • Help family members feel heard instead of blamed or judged. • Develop empathy for everyone on the team - model honesty and make it OK to have all kinds of feelings. • Consciousness-raising, how clearly can clinician address the team concerns and the step by step rationale behind recommendations?

24. Therapist Self Awareness PERSPECTIVE Does this reporting scenario trigger strong reactions for the clinician? Utilize supervisor and colleague viewpoints Consult the literature Map or write out plans clearly CARE When possible, try tp balance caseload Be aware of signs of burn out, whether physical or emotional Have a “menu” of accessible self care tools

25. Goals of Treatment • reduce psychiatric symptoms in parents • reduce family stress • improve family cohesion • address resource problems • address social problems • increase safety for all family members • shift power imbalances in family system • help family understand and adapt to cultural stressors • plan ahead for risks • prevent inter-generational transmission of abuse

26. What does the data say? • Parent education • Relational approach (as opposed to individual) • Multi systemic therapy • Strategic Family Therapy • Functional Family therapy • Gender sensitive family therapy • Therapeutic child care (ITP) • Sexual abuse specific CBT • collaboration with colleagues in law enforcement, child welfare

27. Family Engagement Family involvement is NOT the same as Family Engagement In “involvement” the family is a helper or adjunct, in engagement the family is are empowered key players. Power differentials are explicitly addressed.

28. Case vignettes-discussion questions • Please work in small groups, meet at least 1 new person! • What would be your immediate next action step? • If you choose to report, tell us WHY • What were the red flags & areas of concern? • If you choose to report, tell us IF and HOW you plan to tell the family • Create a plan for how to salvage family engagement and working rapport.

29. Case Vignettes #1 “Pei Chen” 12 year old Pei was raised by her grandmother in China. At the age of 5 she was reunited with her parents in California. Before she was 10, both her parents business and marriage had failed. Her father had a gambling addiction & abandoned them. Mrs. Chen, who is monolingual, now struggles to financially support them. They sleep in the same bed in a tiny rented room within a house with other boarders near Pei’s school. Mrs. Chen has developed severe depression. Her psychiatrist Dr. Lee referred Pei to your children’s clinic. In your 5th session, the family describes an incident when Mrs. Chen started to push & shove Pei “out of frustration” when Pei refused to go to school. When you ask about this incident Pei says “Oh, well that was nothing. The REALLY bad day was when she slapped me and then was beating me up with a clothes hanger for stealing money outta her purse. She told me she wanted to get rid of me-like to an orphanage.”

30. Case Vignettes #2 “Juan & Luz Flores” A school principal referred 15 year old Juan to truancy services. His family are recent immigrants from Mexico. Juan is intellectually disabled so it is particularly vital that he not miss any special day classes. You conduct an assessment home visit. The family is friendly and apologizes for Juan’s absences, but they note that he is very prone to sinus problems and gets ill a lot. You become concerned when you see big bruises on Juan’s limbs. Mr. Flores explains that they had to discipline Juan for “roughhousing” too much with his 4 year old sister Luz when they were bathing together. Juan reportedly slipped in the tub while trying to avoid Mrs. Flores. Juan says “Mom was spanking me with the bath brush ‘cause I pushed Luz into the water and made her cry.”

31. Case Vignettes #3 “Georgia Smith” You have been working with 16 year old Georgia for 5 months. She is a gifted & talented student who attends private school on scholarship. Georgia suffers from bouts of depression and is very “stressed out” by her family situation. For the past 3 years Mom has been a “total recluse” incapacitated by severe depression. All of Mom’s relatives are in Louisiana and they disowned her 17 years ago for marrying a Black man. Mr. Smith is a Gulf War Veteran who reportedly “blames us for everything.” The family survives on Dad’s disability and Veteran’s benefits. Georgia is the only child. Today you decided to call the Smiths due to concerns about the severity of Georgia’s self injurious behaviors - cutting and burning herself. Mr. Smith tersely tells you to “mind your own damn business.” You provide hotline information and try to talk to him about monitoring her safety over the weekend-- he hangs up. 20 minutes later Georgia calls and tells you never to call their house again- “Dad is super pissed.” You explain that you called to ensure her safety and she blurts out, “No, just don’t talk to them-they don’t care! They already know I’ve been cutting, OK?! They didn’t believe me when I got raped at camp 2 years ago, and they don’t believe I’m depressed now. Don’t you get it? Talking to them makes it worse.”

32. Case Vignettes #3 “Amy Fox” Loretta Fox was a single mom raising her eleven year old daughter Amy, until she moved in with Jor 5 years ago and they had their son Benji. You have seen the family for only 3 previous sessions to work on improving communication. Jor seems impatient and demands the children behave “perfectly” and clean up after themselves so the apartment looks “like a magazine picture.” Loretta shows up for session with only the kids today. She looks haggard and anxious. She tells you “Jor is dumping us, he moved out 5 days ago.” When you ask about coping Amy tells you that Loretta whipped both kids with a belt “a lot” and has been unable to get groceries or cook for them. Loretta starts to cry and rock back and forth on your couch, “breaking down” in front of you and the children “Now you’re going to call the cops on me, I’m a bad parent! No one was there for me when my parents were violent to me! How come no one ever helps ME?!”

33. Case Discussions • Did it feel obvious what was the correct course of action? • Did anyone notice a sense of internal conflict about what to do? • Would it feel challenging to sincerely engage with these parents? • How would you approach your work with this family?

34. Remember: • Utilize the treatment decision matrix along with your colleagues and consult team • Model engagement and sincerity in your clinical work as much as possible • Get cultural consults as often as possible • Do not ever risk your own safety! Be realistic when a case must be referred out.

35. Clinicians CAN help families recover from abuse and learn new ways of interaction Catherall (1991) wrote that the key aspect of clinical work with victims recovering from abuse included: “Re-establishment of a trusting relationship with his or her most immediate experience of the human community-the therapist.”

36. THANK YOU! Helen Hsu, Psy.D. City of Fremont Youth & Family Services (510) 574-2100 Hhsu@fremont.gov