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Abstract

RESPONSES TO DISCLOSURES OF SEXUAL ABUSE IN THE HISTORIES OF LONG TERM OUTPATIENT SUBSTANCE ABUSE CLIENTS: AN EXPLORATION OF CLIENT AND COUNSELOR EXPERIENCES

By Katherine D. Rogers

Project Supervisor: Anne Petrovich, Ph.D.

Project Reader: Les Lucas, MFT

May 2002

 

The link between childhood sexual abuse and subsequent substance abuse has been well established in the literature. Paraprofessional counselors who are employed in a substance abuse programs are likely to encounter clients with a history of childhood sexual abuse, yet there is little research on paraprofessional substance abuse counselors' responses to their clients' disclosures of a history of childhood sexual abuse. This qualitative exploratory study examined how the counselors and clients in a long term outpatient substance abuse program respond to the clients' disclosures of childhood sexual abuse. Semi-structured interviews were conducted with six methadone maintenance patients and five substance abuse counselors. It was found that the counselors provide a great deal of supportive therapy to their clients, and that while the counselors are doing beginning work in the first and seconds stages of Judith Herman's model for treatment of trauma issues, the counselors lack confidence in their ability to address trauma in counseling. Recommendations to provide clinical supervision and training to the counselors in order to empower them to provide tins service were made.  

Chapter I - Problem Statement

 

The link between childhood sexual abuse and subsequent substance abuse has been well established in the literature (Wilsnack, et al, 1996; Peters, 1988). A higher incidence of lifetime post traumatic stress disorder in methadone maintenance patients has been documented as well (Villagomez, Meyer, Lin, and Brown, 1995), while other research had shown that higher rates of PTSD predicted poor outcomes in substance abuse treatment (Hi en, Nunes, Levin, and Fraser, 2000).

Research has shown that women with substance abuse disorders are nearly twice as likely to report childhood sexual abuse (Simpson and Miller, 1998, as cited   in Substance abuse treatment, 2000) and that childhood sexual abuse may be a  significant risk factor in women's later substance abuse, sexual dysfunction, and psychopathology (Wilsnack, Vogeltanz, Klassen, and Harris, 1997). However, because "victims of childhood sexual abuse are more likely to have amnesias of the trauma, and a range of dissociative symptoms" (Saxe, et al, 1993; in McFarland and Yehuda (1996), truly accurate data on the incidence of childhood sexual abuse is difficult to obtain.

According to one study, childhood sexual abuse is associated with low rates of secondary school completion, distrust of others, depression, low self esteem, guilt and shame, and difficulties forming friendships (Minnesota Center Against Violence and Abuse, 1998). Other researchers have documented a connection between childhood sexual abuse and other directedness, chronic perception of danger, negative se1fperception, negative specialness, conditional reality, heightened ability to avoid  2 distress, impaired self functioning and tension reducing behavior, and posttraumatic intrusion (Briere, 1996).

Because substance abuse programs frequently employ paraprofessional counselors who have not had formal training in working with sexual abuse or PTSD, an exploration of how substance abuse counselors employed at a local methadone maintenance program deal with these complex issues in counseling proved enlightening.

In the agency in question, counselors typically refer their clients who report a history of trauma to other agencies, county mental health, or private therapists. Because the clients at this agency tend to be of low socioeconomic levels, they are unlikely to seek therapy from a private psychotherapist. Additionally, because they experience the stigma of being heroin addicts, or perhaps because many have poor coping skills, some of the clients at this program have a history of being treated with disrespect by other agencies. As a result of this stigma, few clients follow up on referrals. Indeed, a hastily made referral on the part of a counselor may bring up feelings of abandonment and rejection in the client ("Substance abuse treatment," 2000). This is important to the social work profession, as counselors face the dilemma of how to respond in a clinically appropriate manner to clients who have disclosed a history of sexual abuse.  

Chapter II - Literature Review Theoretical Literature

Treatment of Trauma The literature suggests that there are several accepted models for the treatment of trauma. Most journal articles emphasize the fact that trauma is an ever evolving field of study. Courtois (1997b) detailed a treatment model consisting of four phases: pretreatment assessment; alliance building, safety, and stabilization; de-conditioning and mourning the incest trauma and its consequences; and integration of the posttraumatic material with self and relational development.

Herman (1992) detailed a treatment model for trauma in which the therapy unfolds in the following stages: establishing safety; remembrance and mourning; and reconnection, The advantage of these first two models is that they both break the stages of treatment down into a chronologically linear format consisting of distinct stages of treatment: beginning, middle, and end. There are specific guidelines that assist the therapist in knowing when to apply specific interventions, as applying an intervention in the wrong stage may be harmful to the client.

Another framework for treating trauma was presented by Stevens (1997). In this model, there are three areas to be addressed in therapy: stigmatization, early sexualization, and lack of trust. These categories are further broken down into four subcategories: effect of abuse symptoms, transference, and countertransference, This model has the advantage of explaining how the client's cognitions and behaviors impact the therapeutic process. Thus, it is not only a model for treating the client; it  4 is also a model to assist the therapist in understanding the client. The disadvantage is that it is not presented in a chronologically linear fashion, and does not offer the same guidelines to protect the client as the above models do. 

Substance Abuse Treatment Models

There are many different treatment models for substance abuse treatment in the literature. Byington (1997) described a substance abuse treatment model that incorporates relational theory into addiction treatment. The researcher believes that because women have a particularly strong need to connect to others, she suggests that female substance abusers have developed a relationship with the substance of abuse that may take the place of relationships with other individuals. This treatment approach involves ending the relationship with the substance, which includes a grieving process; building healthy relationships; practicing relationship skills; and strengthening relationships with self, society, and universe. The advantage of Byington's treatment model is that it is specific to women.

Teusch (1997) described a treatment model specifically for use with substance abusing women with histories of childhood sexual abuse. This model suggests that there are four phases of treatment: developing a therapeutic alliance, which may take a year or longer if the client has a history of severe and chronic abuse; maintaining safety, in which the therapist establishes physical safety and psychological safety, and manages countertransference issues; educating the client about the impact of sexual trauma and substance abuse in which the client develops a cognitive understanding of recovery from both substance abuse and sexual abuse; and titrating recovery from sexual abuse and substance abuse, in which the client learns to distinguish between her trauma related feelings and her cravings for the substance. This model resembles the three- and four-stage models for treatment of trauma, but provides a structure for the treatment of substance abuse within that context.

Models for Substance Abuse Treatment Used at this Agency

There are two models for understanding and treating substance abuse that are commonly used at the agency in question. Most of the counseling staff have received training on one or both of these models, either by attending a conference, receiving training from a supervisor, or as part of a degree program. In one of these models, Prochaska, DiClemente, and Norcross (1992) presented an approach to modifying addictive behavior, based on a five stage model. The stages are: precontemplation, contemplation, preparation, action, and maintenance. This model accepts relapse as a part of recovery, and the five stages are not necessarily linear. Rather, they are presented 9-S a spiral model in which individuals may relapse and regress to an earlier stage at any point. The authors recommend specific interventions for each stage of change to assist the client in entering the next stage. Consciousness raising, for example, is a useful intervention during the precontemplation stage, in order to prepare the client for the contemplation stage of change. Educating the client on stimulus control, for example, teaching the client to identify and avoid triggers of use, is a useful intervention in the action stage to prepare the client to enter the maintenance stage. In other words, there are ideal times in the therapeutic process for a counselor to utilize certain interventions. The advantage of this approach in working with a traumatized population is that a counselor who has been trained in this model may find it natural to apply those same principles in working with a client who has been traumatized. Accepted treatment models for trauma emphasize this concept of applying specific interventions at certain times in the therapeutic process (Herman, 1992; Briere, 1996).

Another approach used by some of the counselors at this particular program is Motivational Interviewing. Miller (1998) explained that a key concept of this approach is to understand, accept, and work with the client's ambivalence. Confrontation on the counselor's part, according to this model, leads to denial on the client's part. The counselor does not impose change upon a client, but rather removes obstacles for change. The counselor creates an atmosphere for the client that is warm and safe in order to allow the natural process of change. The counselor accepts that the locus of control lies within the client, and creates opportunities for the client to verbalize negative consequences of current behavior and express a desire to change. 111e therapy is not authoritative; the counselor is not the expert; and the client determines the pace of the counseling. The advantage of this approach is that it too parallels accepted treatment models for trauma which emphasize a therapeutic alliance, in which the goal is to avoid recreating the dynamics of an abuse of power. The therapist in this model empowers the client to be in charge of her own life, forms a collaborative alliance with the client, and does not take sides in the client's internal conflicts (Herman, 1992).

Another approach to working with clients in a substance abuse setting is supportive therapy. Misch (2000) described sixteen strategies of dynamic supportive  7 counseling, which are: formulate the case; be a good parent; foster and protect the therapeutic alliance; manager the transference; hold and contain the patient; lend psychic structure; maximize adaptive coping mechanisms; provide a role model for identification; decrease alexithymia; make connections; raise self esteem; ameliorate hopelessness; focus on the here and now; encourage patient activity; educate the patient; and manipulate the environment.

There are other models and intervention methods of treatment such as hypnotherapy, EMDR, ego psychology, and object relations, all of which require training that is beyond the scope of the typical substance abuse program, and they will therefore not be addressed here. 

Precautions in Working with Trauma Victims

 The literature also suggests that there are specific precautions a therapist should take in working with clients with a history of childhood sexual abuse. Courtois (1997a) detailed nineteen specific steps that a therapist should take in working with this population. The author pays special attention to the pitfalls III working with clients with recovered or delayed memories. The article addresses professional ethics, therapist self-care, and litigation issues .

 Briere (1996) stated that the quality of the therapeutic relationship is at least as important as the treatment techniques. The researcher detailed cognitive distortions that may manifest themselves in therapy. One example is transferences issues, three of which Briere described: cognitive distortions in which the client places the therapist into a specific role such as perpetrator, rescuer, or lover; transference as a result of restimulations of abuse trauma; and transference as a result of attachment issues. Countertransference issues may arise when a therapist has some unresolved sexual abuse issues; this may lead to projection, boundary violation, and avoidance on the therapist's part. Briere also addressed gender issues and explores the advantages and disadvantages of same-gender vs. male/female therapeutic relationships.

Meiselrnan (1990 Chap. 12) used a case study to illustrate her point that a therapist can use specific techniques to avoid the phenomenon of therapist burnout when working with adults molested as children. In addition, she listed warning signs of stress that can be a prelude to burnout, as well as specific steps to take when burnout does occur.

Lott (1999) explored the controversial topic of boundaries in one article. The author explored the role of boundaries in therapy, and listed examples of potential boundary violations in an "yes," "no," and "maybe" format. The article suggests that the deciding factor in whether a behavior is acceptable must be that the behavior in question serves the patient's therapeutic interests. 

Empirical Literature

Linking Childhood Sexual Abuse and Substance Abuse The link between childhood sexual abuse and substance abuse is well established in empirical literature. One study (Wilsnack, et al. 1996) was a ten-year longitudinal quantitative study on women's drinking. There were three waves of data collection in 1981, 1986, and 1991. Questions addressing childhood sexual experiences were included in the third wave of surveys. There were two subsamples: 696 women aged thirty one or older who had been interviewed in 1981, and 403 women aged twenty one to thirty that were new to the study. Ninety-minute interviews were conducted asking about eight specific sexual activities experienced before age eighteen. For each activity reported, follow-up questions regarding the number of individuals involved, the age of the individuals involved, the relationship of the respondent to the individual, and the respondent's feelings about the experience were asked. The outcome of the study suggested that childhood sexual abuse is a significant risk factor in later substance abuse, sexual dysfunction, and psychopathology.

Peters (1988) established the link between childhood sexual abuse and adult substance abuse and depression in another study. Participants were recruited for an earlier phase of this study through random-digit dialing. Face-to-face interviews included questions on both voluntary and abusive sexual experiences. Of the original sample of 248 women, 122 were later located and agreed to participate in the second phase of the study. Three were excluded due to a history of psychosis.

The research model utilized a two-part structured interview, with the first part focusing on the subject's life before age eighteen. The second part assessed the subject for depression, alcohol abuse, and drug abuse as an adult. The sample was divided into three groups: those with no history of sexual abuse, those with a history of contact abuse (fondling, penetration, etc), and those with a history of noncontact abuse (exhibitionism, etc). Of the women in the sample, seventy one percent reported sexual abuse before the age of eighteen, while fifty one percent had more than one perpetrator, and sixty percent involved physical contact. Of the subjects who experienced contact abuse, ninety percent knew the perpetrator. Of the subjects who experienced noncontact abuse, seventy nine percent were abused by strangers.

Using the chi-square method of analysis, researchers found women in the contact group to be more likely to have experienced depression or drug or alcohol abuse. The number of contacts was the strongest predictor of psychological difficulty (psychiatric hospitalizations, past depression, current depression, alcohol abuse, drug abuse, suicide attempts).

The study also controlled for underlying deficiencies in the family and found that the lack of maternal warmth and the duration and number of sexual abuse incidents were greater predictors of depression and substance abuse than sexual abuse alone. The researcher suggests that the combination of these factors place women at greater risk for revictimization as well.

The major strength of this study was that it took into account the possibility that family dynamics other than sexual abuse could contribute to later psychological problems. Because the data on the abuse was gathered in the original study, the interviewers were unaware of which subjects had histories of sexual abuse, and which didn't, allowing for more objectivity. The major weakness of this study is that it didn't discuss "underlying family deficiencies" other than lack of maternal warmth. For example, lack of paternal warmth wasn't explored. 

Impact of Cumulative

Trauma Follette, Polusny, Bechtle, and Naugle (1996) investigated the relationship between trauma symptoms and three types of trauma: childhood sexual trauma, adult sexual assault, and spousal abuse. This study was unique in that it went beyond establishing the phenomenon of revictimization and established that multiple traumas lead to more severe trauma symptoms, further illustrating the need to address trauma when possible in clinical settings.

The study was qualitative, consisting of three portions: a personal data survey on standard demographic information, the respondent's use of psychotherapy services, and the respondent's history of sexual abuse and assault; the use of the Conflict Tactic Scale to assess past or current partner abuse; and the Trauma Symptom Checklist-40 to identify the nature and extent of trauma symptoms. The sample consisted of 21O female subjects recruited from psychological clinics and community advocacy agencies, and 138 female subjects recruited from a university undergraduate program.

Of these subjects, seventy three percent reported at least one type of victimization, while forty nine percent reported a history of childhood sexual abuse. In addition, seventeen percent reported adult sexual assault, and fifty five percent reported physical abuse by a partner, An analysis of variance was conducted based on the number of types of trauma experienced, with the dependent variable being the TSC-40 score. The results indicated a high incidence of trauma among both clinical and non clinical subjects, and also suggested that the effects of multiple traumas was cumulative, with the subjects with histories of multiple traumas showing more severe symptoms of trauma.  

Long Term Impact of Child Sexual Abuse

Five empirical studies that explored the long term impact of childhood sexual abuse were reviewed. In an early descriptive study Lindberg and Distad (1985) explored the connection between incest ~U1dposttraumatic stress disorder. Seventeen women who had been victims of incest and had entered therapy for a variety of complaints, none of which were initially recognized by the participants as being related to the incest, were interviewed and assessed. All of the participants were found to meet the criteria for PTSD. Narrative excerpts were included in the article to illustrate how such criteria was met by various participants.

The study also found that incest victims were similar to Vietnam veterans in that the onset of posttraumatic symptoms may be delayed for days, years, or decades. The researcher offered treatment guidelines similar to the guidelines that were in place at the time to treat combat related PTSD. One limitation of this study was that the correlation between incest and PTSD does not necessarily establish that the relationship is a causal one. Another limitation is that while it appears that incest victims tend to develop PTSD, the sample was biased in that it was strictly a helpseeking clinical sample.

Because the long-term effects of childhood sexual abuse in psychiatric populations were established in previous studies, one study sought to examine the effects in a nonclinical sample (Briere and Runtz, 1988). In this study, 278 college students were recruited to participate in the study, receiving college credits as a result. Each participant was given a Family Experiences Questionnaire made up of a survey of childhood sexual experiences and two versions of the Hopkin Symptoms Checklist (IfSCL). The HCSL scales assessed acute and chronic somatization, anxiety, depression, interpersonal sensitivity, and obsessive compulsive symptoms. The scales were modified to include an assessment of dissociation. Of the 278 students, more than fourteen percent reported a history of child sexual abuse. Sexually abused subjects scored higher than nonabused subjects on acute and chronic dissociation and somatization, and on chronic anxiety and depression.

Correlation analysis indicated the following significant relationships between specific abuse variables and symptomatology: the age of oldest abuser was associated with reports of chronic anxiety and acute and chronic dissociation; the threat and use of force was positively related to higher acute somatization, while parental incest was associated with chronic somatization, anxiety, and depression. Total number of abusers was associated with chronic anxiety and depression, while total duration of abuse was associated with higher chronic somatization, anxiety, and depression, and acute and chronic depression. In summary, the study found that university women with a history of child sexual abuse reported higher levels of acute and chronic dissociation, anxiety, and depression, compared to a group of university women without a history of childhood sexual abuse.

The weakness of this study was that the sample consisted of only university women, which may have screened out less functional victims of abuse. The significance of this study was that its recruitment of non clinical participants suggests the existence of large numbers of sexual abuse survivors who have not sought mental health services for their symptoms.   

Greenwald and Leitenberg (1990) explored the extent to which PTSD symptoms were reported in a non-clinical sample. The study also explored whether the level of sexual activity involved in the abuse was correlated with later PTSD symptoms and whether the relationship of the perpetrator to the victim has any impact on the later PTSD symptomatology of the victim.

Questionnaires were given to 1500 female nurses in two hospitals. Women who had been sexually abused were asked to complete the questionnaires and return them. Only fifty four women (less than four percent) responded. Subjects were asked if they experienced specific PTSD symptoms in the past week or prior to the past week. The subjects were also asked to rate each symptom's severity on a 5-point Likert scale.

The results of the study indicated that the extent of PTSD experienced in tills nonclinical sample was not substantial. However, PTSD was found to be more likely to occur and more likely to be severe in father-daughter incest and in cases where intercourse occurred. There are several explanations for the finding that PTSD in this sample is not substantial. First, very few of the potential respondents actually responded, which may be because the members of the sample with substantial PTSD symptoms of avoidance chose not to respond. Second, this sample had fewer instances of father-daughter incest victims than other studies, possibly resulting in fewer with substantial PTSD symptoms. And third, this sample was not drawn from a clinical help-seeking population; it was drawn from a professional, functional population, suggesting that the sample may have been skewed.  

 Alexander (1993) examined the effects of sexual abuse characteristics and adult attachment on long-term outcomes. In this study 112 female incest survivors were recruited from the community, They were asked to complete six questionnaires and scales: Sexual Abuse Characteristics (age of onset, degree of force, and relationship to perpetrator); Relationship Questionnaire to determine adult attachment style; Beck Depression Inventory; Symptom Checklist-lO; Impact of Event Scale; and Millon Clinical Multiaxial Inventory-II. In the sample, fifty eight percent were found to have a fearful attachment style, compared to twenty one percent in a normative sample (Bartholomew and Horowitz' study, as cited in Alexander, 1993). Hierarchal regression analysis showed that overall the subjects in the present study were found to have elevated levels of depression and distress as well as avoidant and self defeating personality traits. The basic personality structure, such as self defeating, avoidant, and dependent personality traits were not associated with abuse characteristics, but rather with adult attachment. This suggests that effective treatment requires a feeling of interpersonal security such as that established through the support of caregivers in childhood, current adult supportive relationships, or trust in a therapist. The researcher also suggests that a healthy therapeutic relationship can legitimately be regarded as a goal in therapy at a particular point in therapy. The limitation of this study, however, was that it included victims of incest only, and the results may not be generalized to all sexual abuse survivors.

The relationship between the level of childhood sexual abuse exposure and the subsequent development of posttraumatic stress disorder was examined in a study conducted by Rowan, Fay, Rodriguez, and Ryan (1994). Prior to this study, standardized instruments to assess PTSD were rarely used. This study utilized the Structured Clinical Interview for DSM-III-R (SCID), the Impact of Events Scale (IES), and the PTSD Symptom Checklist (SCL). Because previous studies did not operationalize childhood sexual abuse, and because data on the array of childhood sexual abuse was rarely collected, the researchers i11 this study developed the Sexual Abuse Exposure Questionnaire (SAEQ) to assess the nature and severity of the abuse.

Forty-seven adults who had disclosed histories of childhood sexual abuse were recruited through their therapists. The results from the SCID found that sixty nine percent of the participants met full criteria for PTSD, while the results of the SCL found that sixty four percent did so.

A chi-square analysis revealed no significant relationship between demographic data and a diagnosis of PTSD. A chi-square analysis also showed that there was a significant correlation between the severity of the abuse and a diagnosis of PTSD on the SCID. Specifically, duration and frequency of the abuse were most significantly related to a diagnosis of PTSD. However, no significant relationships were found between general or specific exposure variables and a diagnosis of PTSD using the SCL. A con-elation between the intensity of PTSD symptoms and the duration of the abuse was discovered. Age of onset was not significantly correlated to a diagnosis of PTSD using either scale.

This study had several weaknesses. First, the high numbers of PTSD diagnoses could be due to the use of a clinical sample of help-seeking childhood sexual abuse survivors. Second, variables such as length of treatment, periods of memory repression, and amount of time since disclosure were not taken into account and could have affected the results of the study. What the study did establish was that PTSD is a potential outcome of childhood sexual abuse, particularly in individuals who experienced higher levels of exposure.

Responses to Disclosure

While many studies have shown a link between childhood sexual abuse and later psychological difficulties, one study found a correlation between responses to disclosure and later psychological difficulties (Everill and Waller, 1995). In this study, the researchers compared their results to a previous study of eating disordered subjects who had reported a history of unwanted childhood sexual experiences, a study in which a link was found between perceived negative responses to disclosure and future psychological difficulties (Waller and Ruddock, as cited in Everill and Waller, 1995).

Because the earlier study was limited to a specific population of eating disordered individuals, the later study recruited nonclinical subjects. This study explored two primary questions: Was a positive response to disclosure as rare as in this non clinical sample? And, was psychopathology greater in those subjects who reported a negative response, when compared to the subjects who reported no abuse, reported abuse and no disclosure, and reported disclosure with positive response?

The researchers recruited sixty nine female undergraduates to participate in the study. Each subject completed questionnaires on eating pathology, psychological functioning, and histories of unwanted sexual experiences. Of the sixty nine women, forty nine reported abuse. Of those, thirty four reported an attempt at disclosure. Of  18 those, seven reported an adverse response to disclosure. In the previous study of twenty seven eating disordered women, twenty five reported adverse responses.

A chi-square analysis of this data showed a significant difference in distributions across the two populations, due to the larger number of supportive responses in the current study. In addition, women who reported adverse responses also demonstrated greater levels of psychopathology on all of the measures of non-eating characteristics. Specifically, a perceived adverse response was associated with higher levels of self denigration and dissociative experiences .. Because in this study "adverse response" to disclosure was operationalized as "no response" or "hostile response," it illustrates the importance of a counselor acknowledging the disclosure and meeting it with sympathy and support.

Effectiveness of Treatment of Trauma

While there appears to be little research on the effect of counseling on treating trauma, one study did compare the effectiveness of three different types of counseling provided to rape victims and found that cognitive behavioral therapies were more effective than supportive counseling (Foa, Rothbaurn, Riggs, and Murdock, 1991). Patients in this study were recruited from referrals from local professional therapists and victim assistance agencies, recruitment by local newspaper advertisements, and patients from an assessment study on rape. All of the subjects met the DSM-ill criteria for PTSD three months after the assault. There were forty five subjects III all. Some additional subjects were also recruited from a waiting list to serve as a control group (WL). However, the forty five were placed into three groups: a group the received Prolonged Exposure (FE), a group that received Stress Inoculation Training (SIT), and a group that received Supportive Counseling (SC) with no instructions for exposure to anxiety management.

Immediately after the course of treatment, patients in the PE and SIT groups were found to have fewer PTSD symptoms, with the SIT group showing the most improvement. The SC and WL groups showed improvement in arousal symptoms, but not intrusion and avoidance symptoms. Three and one-half months post-treatment, however, the PE group showed the most improvement. An ideal treatment program, the researchers suggest, would contain components of both SIT and PE in order to reduce more PTSD symptoms in the long and short term. The study also suggests that SC is better than 110 treatment, as the SC group showed more improvement than the WL group, but is not the ideal treatment.

The Prevalence of PTSD in Methadone Maintenance Patients

Villagomez, Meyer, Lin, and Brown (1995) established that the percentage of methadone maintenance patients with a lifetime diagnosis of PTSD was significantly higher than that of the general population. In this study, the sample consisted of 766 methadone maintenance patients in six inner city substance abuse programs. Each participant had more than a one-year history of opiate dependency. Between two and six weeks after admission, each participant was interviewed and assessed with the Quick Diagnostic Interview Schedule and the Addiction Severity Index. Of the 753 participants who completed the study, more than fourteen percent were classified as having met the criteria at some point in their lives for a DSM-III-R diagnosis (lifetime PTSD diagnosis). The percentage of women was significantly higher (more than nineteen percent) than men (eleven percent). These percentages were higher than those of the general population (less than two percent among women, and less than one percent among men) (He1zen, Robins, & McEvoy (1987), as cited in Villagomez, Meyer, Lin, and Brown ,1995). The most common traumatic event reported. by women was rape, while the most common event reported by men was witnessing violence. The weaknesses of this study, according to the authors, was that it focused on strictly inner city, and primarily methadone maintenance, which may not accurately represent the percentages of PTSD in overall methadone maintenance patients. Another weakness acknowledged by the researchers was that the participants may not have correctly identified their precipitating traumatic event. The researchers listed the events identified by the participants, and then listed events considered traumatic but not identified by the participants, including marital rape, domestic violence, and violence within the gay/lesbian community. It is unclear whether childhood sexual abuse was considered a traumatic event by either the participants or researchers.

Clark, Masson, Delucchi, Hall, and Sees (2001) also established that a higher percentage of women than men in methadone treatment were diagnosed with a lifetime diagnosis of posttraumatic stress disorder. In this study, 150 methadone maintenance and long term (180 days) methadone detoxification were interviewed at baseline and monthly for twelve months. The Computerized Diagnostic Interview Schedule was used to assess substance use and DSM-III-R defined psychiatric disorders. Participants rated their traumatic symptoms on a six point scale, according to the amount of time that had elapsed since the symptoms had last occurred, ranging from within two weeks to more than a year ago. Of the 150 participants, forty four (twenty nine) were classified as having a lifetime PTSD diagnosis. A significantly higher percentage of women (fifty three percent) than men (fourteen percent) met the diagnostic criteria for lifetime PTSD. Fifty-five percent of the participants who had a history of PTSD reported having experienced trauma related symptoms in the last six months. The participants were asked to identify what they perceived to be the precipitating traumatic events, and were limited to identifying three events. The most common events identified were rape, physical assault, and witnessing violence, with women reporting rape in greater numbers than men. While the weakness of this study is that it is unclear whether childhood sexual abuse was considered a precipitating traumatic event by participants, the strength of this study is that it identified that a large number of methadone maintenance patients continue to experience trauma related symptoms, emphasizing the need for treating trauma in substance abuse programs.

The Effect of PTSD on Methadone Maintenance Treatment

Hien, Nunes, Levin, and Fraser (2000) demonstrated that childhood physical and sexual abuse and adult exposure to violence were associated with higher rates of PTSD, which in turn predicted poor outcomes in substance abuse treatment, as measured by polysubstance abuse. Ninety six newly admitted methadone maintenance patients participated in a two-hour interview conducted by licensed psychiatrists and psychologists and were evaluated for DSM-IV Axis-I diagnoses, including PTSD. Each participant was also given the Traumatic Event Questionnaire in order to determine which traumatic events participants had experienced. Participants were asked to rate the severity of the events, and whether it had occurred in the last six months. The age of onset at the time of the event and number of events were also ascertained. Over :fifty percent reported one nonviolent traumatic event in adulthood. Forty percent of women reported a history of partner violence, and nearly thirty percent reported a history of childhood sexual abuse.

Participants were also given the Drug Use Questionnaire to ascertain drug use patterns. Bivariate analyses indicated that current PTSD predicted higher overall rates of poly substance abuse three months into treatment.

Therapist Self Disclosure

The effects of therapist self disclosure was examined in two studies. One qualitative study involving thirteen long term therapy clients (Knox, Hess, Peterson, and Hill, 1997) established that a therapist who discloses personal information about his or herself to clients resulted in clients perceiving their therapists as more human and real, in clients feeling reassured that their struggles were normal, and in clients using the therapist as a role model to make changes in their own lives.

Another study (Berman, 2001) of thirty six clients from an outpatient psychotherapy clinic and eighteen therapists revealed that the clients reported fewer symptoms of distress as measure by the Hopkins Symptom Checklist, when their therapists increased the number of self disclosures in therapy. Transcripts of therapy sessions were analyzed for instances of therapist self disclosure, Clients were interviewed regarding their symptom distress before the first session and after all sessions.

While there is a substantial amount of research on the correlation of substance abuse and trauma, the treatment of trauma, and the treatment of substance abuse, there appears to be little empirical literature on the efficacy of the three- or four-stage models of treating trauma, or on paraprofessionals addressing trauma in substance abuse programs. A search of the Psychlnfo database on the terms "trauma," "paraprofessional," and "substance abuse" yielded 9646, 276, and 9925 results respectively. A search combining the three terms yielded no results. A search on "trauma" and "paraprofessional" combined yielded only eight results, with three articles addressing emergency response paramedics, and three others addressing caregivers and nursing assistants. The remaining two articles did concern paraprofessionals and trauma, but the subject matter was secondary trauma in paraprofessional counselors following critical incidents. According to Ruben and Babbie (1997), exploratory research is conducted to provide a beginning familiarity with a topic. When the subject is new or unstudied, exploratory research is recommended. In addition, according to Sheridan and Kisor (2000), qualitative analysis is useful in exploratory studies where there is little research on a topic. Due to the poverty of research on paraprofessionals addressing trauma in a substance abuse setting, a qualitative and exploratory methodology was chosen for this study. 

Chapter III - Methodology

The primary research question is as follows: what is the specified substance abuse program doing to address the needs of its female clients who have histories of childhood sexual abuse? The unit of analysis was individuals, both clients and counselors. The substance abuse program has three sites in Fresno. One with 440 methadone maintenance clients, one with 470 clients, and one with 600 clients. Approximately one third of the clients at these programs are female. Two of the three programs participated in this study. Two populations were targeted in this study: counselors who have clients who have disclosed a history of childhood sexual abuse to them, and clients who have a minimum of thirty days since their admission to the program, and who have disclosed a history of child sexual abuse to their counselor. The counselors who work in these two programs were asked in a letter of introduction if they would be willing to participate in a study. Those counselors who met the criteria and responded affirmatively were given letters of introduction to recruit clients who met the criteria who would be willing to be interviewed. Formal informed consent was given at the interview. One program had a high turnover of counseling staff in the past year, and therefore had few counselors who met the criteria. In order to avoid eliminating clients from the study who had disclosed a history of sexual abuse to previous counselors, but had not yet disclosed to current counselors, some clients were approached by the researcher, and given the opportunity to participate in the study if they met the criteria by disclosing to a previous counselor. This method of recruitment was successful in each instance. Five counselors were interviewed, and six clients were interviewed. Of the counselors, four were female while one was male. Two had master's degrees, while three had bachelor's degrees. The only counselors who had prior experience in working with trauma victims were the counselors who possess master's degrees. Of the six clients, four were recruited through the counselor, and two were approached by the researcher. Five clients were female, while one was male. Although the criteria specified that all client participants would be female, the researcher believed that a male client could offer some valuable information.

Counselors who participated in the study were provided lunch from Abe's Happy Subs, and clients who participated in the study were given a five dollar gift certificate from McDonald's.

Some of the questions that were explored were: What are the treatment needs of this population with respect to their sexual abuse? To what extent are the treatment needs being met by the program? What else can the program do to meet these treatment needs of this population? Is it feasible for a substance abuse program that employs paraprofessionals to address the effects of trauma in the treatment of clients?

Consent was obtained from the individual clients, the counselors, and the agency. The human subject issues encountered included: the need to protect client and staff confidentiality, and the possibility of retranmatization by asking questions that may trigger flashbacks or severe depression. The participants were assured that their responses will not result in any harm coming to them. The counselors were assured that their evaluations, their raises, and their positions were in no way be affected by their participation in the study or by the answers that they provide, and that the data was to be held in the strictest confidence. The clients were assured that their continued participation in the program, their relationship with their counselors, and their privileges at the program would in no way be affected by their participation in the study, or by the answers that they provided, and that the data was to be held in the strictest confidence. In order to safeguard confidentiality, a numerical code was placed on each consent. That code was then used to label the tapes and the interview transcripts. The consents were kept in a locked file cabinet to which only the researcher had access. After the tapes were transcribed, they were destroyed in order to prevent voice identification.

The emotional health of the participants was safeguarded by giving each participant the phone number of Rape Counseling Service's 24-hoUT hotline staffed by trained crisis counselors and by giving them the phone number to the PACT unit (Psychiatric Center for Assessment and Treatment) in the event of suicidal or homicidal ideation. Each participant was given the opportunity to be informed of the results of the study.

Because there is very little research on paraprofessionals working with trauma, a qualitative data analysis method consisting of a semi-structured interview of a target group of clients was used for this study, Each participant was given a questionnaire with fixed response questions, both to gather specific demographic data and to serve as an ice breaker. Clients were asked their age, ethnicity, the number of times they have received counseling in another agency for sexual abuse issues, and the drugs of use and abuse. The researcher then progressed to a semi-structured open ended question based interview. Counselors were asked their age, level of education, number of years of experience in working in substance abuse, number of years in working in human services, and specific training they have had in trauma. A nondirective approach was used, as it was less likely to cause retraumatization, and because it would allow the information to be generated from the respondent. If clarification was needed, the researcher could interact with the participant. According to Reinharz (1991) this approach allows for exploration of the interviewee's view of reality, and allows the researcher access to their thoughts, ideas, and memories in their own words. In addition, an open ended, nondirective approach was used as it may have been perceived as less controlling and less intrusive or threatening to clients who have felt powerless at one point in their lives. The researcher transcribed the interviews and then analyzed them for common themes and patterns, and then coded the data accordingly. In this particular study, Herman's model for trauma work and Misch's model for supportive counseling (2000) were used to operationalize both types of counseling. Responses indicating supportive counseling and trauma work were then identified and counted by the researcher. Individual quotes were used to illustrate common themes in the interviews in a manner similar to the one described by Reinharz (1992).

This exploratory, qualitative research design is appropriate for the initial stage of inquiry into a new area of knowledge. It is commonly known that many persons who have problems with substance abuse have a history of childhood sexual abuse, and this history has been shown to have long term consequences in the lives of these individuals. Patients participating in a methadone maintenance program have been shown to have a higher incidence of PTSD than the general population, with many reporting trauma related symptoms within the last six months, and these symptoms have a direct impact on the outcome of substance abuse treatment. The presence of individuals in a substance abuse program with histories of childhood sexual abuse offer a unique opportunity to begin addressing trauma issues that directly impact on recovery from substance abuse. This study provided a beginning understanding of the feasibility and development of an effective design of treatment approaches in the . context of a long term outpatient substance abuse program.  

Chapter IV - Findings

The most common theme that the researcher identified in this study was that the counselors who participated in this study were providing a lot of dynamic supportive psychotherapy to their clients. Of the many skills described by Misch (2000), there were three strategies that appeared to be employed frequently by all the counselors interviewed: Foster and protect the therapeutic alliance; be a good parent; and raise self-esteem by fostering competency and encouraging employment.

According to Micsh, fostering and protecting the therapeutic alliance includes developing trust, respecting the client as an individual, identifying and allying with those parts of the patient that are the healthiest. TI1eparticipants in this study referred to this strategy forty six times, the most frequent of any strategy used. There were eighteen examples of respecting the client as an individual. One client described how she felt her counselor treated her:

She's always made me feel that she's been interested in me, not just as a counselor, but as a human being. She has always made me feel as though she really cared for me, and I just feel comfortable with her. One counselor illustrated how she respects her clients as individuals by describing what she does upon meeting her clients for the first time: I try to show them right away that I care about them, that they are my clients, so my responsibility is to help them and I really want to help them. I don't want them to pass through the program like nothing.  

 

Developing trust is a large part of forming the therapeutic alliance. Trust was mentioned eight times by participants. One client described developing trust with her counselor, "I think basically I felt I could trust her. It took a long time. I felt she really cared, really was interested in my life. I didn't feel she was bored."

Confidentiality, which contributes to developing trust in the context of the therapeutic relationship was mentioned eight times. One counselor explained why she believed her clients disclosed their histories of sexual abuse to her: "I guess somehow I assure them that I'm not going to tell anybody, this is confidential."

Another counselor echoed the belief that confidentiality within the clinic played a role in her clients' decision to disclose to her:

 I don't think my clients in general know what emotional safety means, and they've never had that. My feeling is that when they realize that it's going to be confidential, that it's not going to leave this r00111 unless it's something really drastic .... I think when they realize ... that she's not going to be running around telling everybody, [they will disclose].

There were six instances of participants referring to counselors trying to identify the healthy parts of the client. For example, one client explained:

There's been so many times I've called [my counselor] in a state of rage, you know? Like really wanting to hurt myself because I'm so angry at certain people, and I feel I can't do anything about it, but then she reassures me that I've come a long way, that I'm a good person. 

Another client stated, ''Days I might think I'm doing wrong, she reassures me that I'm doing right."

One counselor simply stated, "I try and point out their good qualities, to show them, 'You're headed in the light direction.'"

Being a good parent was also a strategy that was utilized by the counselors who participated in this study. Misch (2000) stated that being a good parent in the context of supportive counseling means comforting and soothing; suggesting, advising, and teaching; and assessing, monitoring, and confronting self destructive behaviors. The researcher in the present study identified a total of thirty examples of being a good parent: fifteen references to comforting and soothing, eight references to educating, and seven references to assessing, monitoring, and confronting self destructive behavior.

Two counselors eloquently expressed attempts to soothe and comfort. One stated that when her clients are upset about something.

I somehow tend to lean towards them a little bit .... I speak in a calmer manner .... When it comes to crying, you know, I try to give words of comfort, some hope. "Hang in there" and that kind of thing. If they seem to need a bug, 1 give them a little hug.

Another counselor described her attempts at soothing clients who are distraught:

I hand them a Kleenex. And then I grab one. You now, just to let them know that it's OK. I don't just hand them one; I grab one for myself .... There's some clients I feel comfortable with, the women, that when they get up to leave, I always, like, I grab their shoulders and let them know it's OK, you know, you'll be fine. So I have touched their shoulders. I let them know that it's OK. It's OK to cry. I guess that's comfort. I comfort them.

 

Suggesting, advising, and educating was another method of being a good parent. Most counselors attempted to provide some sort of education to their clients on childhood sexual abuse. As one counselor stated:

Eventually, somewhere down the line, we're going to be talking about how this has impacted their lives. If they want to get that far into it ... we can get into "this is what happened here." Trust issues. Betrayal of trust is a huge issue. Feeling Mom didn't protect you, or whoever. Not only did they betray the trust, but they stole the childhood. So we gotta deal with that. How do you think it's related to your drug use and other behaviors that happened? Prostitution, and a lot of these other things that are pretty easy to see how this process happened.

 

One client described how her counselor provided education to her in the issue of child sexual abuse:

Yeah, I talked about it with [a previous counselor], That’s really the only one I talked to about it. And what he did was, he said, "I'm going to go home and get on my computer, and I'm going to print out all the information I can get." And so he did that, and he brought it In, and we talked about it. And I did feel better, because he could give me some answers. And that's what you're looking for.

 

There were several instances of counselors monitoring, assessing, and confronting self destructive behaviors in this study. One of the clearest examples came from a counselor describing what she does when she first meets a client:

I tell them right away that I want to help them, that I'm going to monitor their progress, so basically someone cares enough about them to make sure they are doing what they need to do to help themselves .... So someone is looking out for them, so they can get that feeling, like, "OK, then someone's going to be watching me, so maybe I should try and do good."

 

One client described her perception of that same process:

I would like to see more counselors like mine that really care. I shouldn't say these words, but I used to think she was a tough ass. I used to hide from her. She made me feel like she's here to help me, and she makes me feel she really cares.

Raising self esteem is also a strategy utilized in supportive counseling. Two specific methods of raising self esteem described by Misch are: fostering competency, which include relieving the client of guilt; and encouraging employment. In this study, there were twenty three references to raising self esteem by one of these two methods: eighteen of these references were in the context of relieving guilt, and five in encouraging employment. One client explained what her counselor did to help her with her guilt feelings surrounding her molest issues:

I walked into her office so loaded down with guilt and everything. I felt like it was my fault. I felt really guilty .... She said, "It's not your fault. Calm down now!' She told me I wasn't taking the baggage out of the office, that was the whole purpose in talking about it. It helped me pull myself together.

 

A counselor offered the following opinion about how to handle guilt feelings surrounding molest issues: "They need to know that what they went through isn't their fault, and a lot of times, they think they did something, and they carry it."

Another counselor explicitly linked the relief of guilt to improved self esteem: The first thing I like to do with a client is have them focus on the fact that they may not have had control over what was going on, so that they need to take that burden off their shoulders. And so that's part of trying to break that wall there, so that they can start feeling better about themselves.

 

While encouraging a client to seek employment may not playa role in treatment of trauma per se, Misch stated that it does playa large role in improving self esteem. Five counselors of the five interviewed stated that they encourage their clients to seek employment. One counselor explained her belief that it was directly related to self esteem, "Family is very important. Work. Self-worth. I mean, if you feel you are contributing somehow, you feel your work shows your effort by getting paid."

 

Another counselor explained what she generally discusses with a client upon the first meeting:

I try to get a little of their education, their employment, their history. If they're not doing that, are they on SSI? Are they receiving benefits for [TANF] or something like that? And then if they are interested in going back to work, if there are any programs like Cal Works, what do they see in their future?

 

Another pattern identified in this study is that the counselors who participated gave indications that they were doing some work with their clients in the first and second stages of Herman's model for treatment trauma: Safety, and Remembrance and Mourning. In the Safety stage, the focus of therapy is to address the client's needs for physical safety, initially by helping the client to feel safe in his or her body, and then to help the client to feel safe in his or her environment (Herman, 1992). Helping a client feel safe in his or her body can take the form of monitoring medication, encouraging relaxation, and monitoring basic health needs. Counselors who participated in this study referred to this type of intervention twelve times. There were two references to medication, four to relaxation, and six to basic health needs. One counselor referred her client for assessment for antidepressants:

When she disclosed the information to me, like I said, I thought that she was going into a depression about it. I did ask her to see our nurse practitioner about it so that he could assess whether she needed antidepressants. Another counselor addressed the importance of relaxation: I think that stress has a lot to do with a lot of issues. For example, [for] one client, [having been molested is] one thing that adds to the stress that she goes through. And so I think, maybe with her, I asked, "When you're stressed out, and you don't know what to do, have you thought about doing something like exercises? Not anything major, but when you're all tense, when you've got knots here and there, just doing a1111exercises, leg exercises .... " I even show them.

 

 Addressing basic health needs is a constant with this population who has a history of engaging in high risk behaviors. It's not surprising that basic health needs are being addressed by counselors at tins agency:

Health is very important. Some have diabetes. We talk about medication. "Are you going to the doctor, make sure you get checked?" For women, annual exams. Depending on what age, we talk about having peace of mind. "If you don't go to the doctor and get those things checked, what if something comes up later because you didn't do it?" I talk about prostate cancer, especially if the are fifty. And: I have a lot of older clients, and we deal with a lot of health issues. Risk factors that they continue to indulge in, whether it's chemical abuse, either illegal, or smoking, bad diet, or whatever they're doing. That is a constant with mine. Constant health issues.

 

Counselors also gave responses that indicated that they were aware of the need for clients to feel safe in their environments. Some counselors addressed family issues in general:

 In relationship to friends, many of the clients obviously have relationships with other individuals who use illicit drugs, so it's very difficult for them to leave those associations ..... When it's their family members, it becomes even more difficult. They feel they're not going to sever those ties with their brothers or their sisters who are also drug abusers.

 

In discussing ethical concerns in reporting suspected current sexual abuse, one counselor addressed family issues as it relates to trauma:

And another thing is that when we have women who were abused by their fathers, who are also their sole support, and that's who has also loved them and supported them, that have also abused them. So it's kind of hard to report them because you're also taking your client's source of support away.

 

According to Herman, "If the therapist believes that the patient is suffering from a traumatic syndrome, she should share this information fully with the patient. Knowledge is power. The traumatized person is often relieved to learn the true name of their condition .... No longer imprisoned in the wordlessness of her trauma, she discovers that there is a language for her experience. She discovers that she is 110t alone; others have suffered in similar ways" (Herman, p. 158).

Although the counselors at this agency do not attempt to diagnose traumatic conditions in their clients, they do recognize the value of sharing information with their clients, of assuring the client that she is not alone in her trauma. This was demonstrated in the previous discussion of counselors who utilize the "Be a good parent" strategy of providing education. As stated above, there were eight references to counselors providing education and information to their clients regarding trauma. In fact, the Safety stage described by Herman can be likened to "Being a good parent" in supportive counseling, as a good parent will attempt to ensure that their child feels safe in her body and her environment. It is therefore not surprising then that the counselors at this agency are doing some work in Herman's first stage of trauma work.

What might be more surprising is that there were fifty two references to counselors providing interventions in Herman's second stage of trauma work, Remembrance and Mourning. It must be clarified that eight of these references were simply instances of clients and counselors acknowledging clients' trust issues, and not necessarily mourning the loss of trust or the loss of the childhood. Further research would have to be conducted to determine what exactly counselors are doing in response to identifying this issue. However, there were twenty six explicit references to counselors encouraging their clients to talk about the trauma, and six instances of counselors engaging in a careful exploration of the traumatic events.

One client illustrated the importance of a counselor being receptive to hearing their story:

In the past, I've had other counselors at [other clinics] and I tried to talk to other counselors about it, and he would never bring it up, and he'd always tell me to just forget about it, that I should put it out of my mind .... It was the same thing my mother told me. I felt like no one cared. I felt abandoned again, like no one cared, like I didn't matter, or that anything that happened to me really counted.

 

Another client was acutely aware of a counselor's body language upon hearing her disclosure: "He did not change his demeanor, it did not make him uncomfortable, he did not fidget .... If something like that happened to me again, he's probably the first person I'd talk to about it."

Counselors too were aware of the importance of encouraging a client to talk about the trauma. One stated:

I think that within myself, I thought, "OK, I'm going to stay calm about this. I'm not going to change my look or bat my eye, to give her the feeling of' Oh, maybe I shouldn't have said that.'" And then I asked, "Well, do you want to talk about it?" And then she began to explain it to me.

Another role-played what he would say to a client he suspected wants to disclose:

Not only am I your counselor, but I'm a counselor that feels that we've grown close in am counseling relationship, that there is nothing you can tell me that is going to leave this office. There is nothing you can tell me that is going to make me think bad of you. And I hope you feel comfortable enough, whatever it is you want to tell me, I hope you feel comfortable enough to let me know what's going on in your life, what's going on in your past.

 

While there were many examples of counselors encouraging clients to talk, there were fewer instances of counselors engaging in careful exploration of the trauma, but there were several indications that it was being done. One counselor explained, "I've listened, basically. I've asked them what it feels like, do they remember what it feels like, kind of relate it to their drug use, to feeling powerless."

 Another counselor stated:

I may start to ask a few questions. A little bit of probing. If they say, 'Daddy did whatever," it can be "When did that start?" or something like that. It doesn't usually take too much before they start to get going.

 

Yet another counselor stated:

As far as not digging enough or digging too much, I have never felt that was a problem, because each person is different. Very carefully, I'll dig a little deeper. If that person is receptive, fine. If not, I back off. It's kind of like you're testing the waters.

 

Other strategies used during the Remembrance and Mourning stage employed by participants in the study include: five references to counselors normalizing responses; two references to counselors reviewing the meaning of the traumatic events; two instances of clients discussing revenge fantasies; and one each of a counselor attempting to get the factual data of the trauma, a counselor assisting a client in mourning the lost childhood, and one counselor demonstrating her ability to reassure a client that the pain isn't going to last forever:

If they're crying, I let them cry it out. Even if they're mad at that point, even if they're mad because they're crying, if they want something more from me, I tell them, "You're going to be dealing with it, and you're gonna be OK." And they are. Just because they cry doesn't mean they're never going to stop. People think that the floodgates have opened, but it doesn't work that way. No one has ever cried for the rest of their life.

 

While the counselors who participated in this study did show some evidence that they were dealing with the issues of childhood sexual abuse as it was disclosed in counseling, that doesn't necessarily mean that the counselors are entirely comfortable in addressing the issue or are confident in their abilities. Of the five counselors, two expressed concern about their own abilities. While this was a very limited sample of counselors, the level of confidence seemed to be directly related to the level of education. Two of the three counselors with an undergraduate degree expressed a lack of confidence in their own abilities:

Well, first of all, we're not trained to deal with deep issues like that, so I know there is a limit. We talk about certain things where I feel that's it's safe for me to hear them out, so that they feel they can talk to someone, especially if they've never talked to someone. But when it comes to certain things, I still refer them to Mental Health. They specialize in that. ... It's safe to go and talk about certain things, but when you feel like you're getting a little uncomfortable because you don't have a lot of knowledge on it, or touching something very deep that - you need to be careful not to go very deep. You might bring out something you're not prepared to deal with.

Another bachelor's level counselor expressed:

I never get graphic. I never ask a client to say exactly what happened. I think that's too traumatizing for them. I think that's crossing my lines of counselor. I think I need to refer them to a rape counselor or specialist to really deal with that aspect. I mean, I would not get graphic at all .... Well, I'd definitely let them talk, but I wouldn't engage. I feel that it's too traumatizing, and I have to realize my limits as a counselor.

One counselor with a graduate degree was confident in her abilities, but felt that the structure of the agency didn't allow for trauma work:

For me personally, I've gotten training, and I still think that the best training that you can get is having a supervisor you can discuss the case with. So I think you always need to go and discuss something like that, but here, we don't have it.

 

When the researcher in this study was recruiting participants, the two counselors with graduate degrees volunteered upon hearing about the study, while the counselors with bachelor's degrees did not commit to participate until they were actively approached by the researcher. While this might reflect that those with graduate degrees have a greater appreciation of the value of research to the profession, and of the importance of participating in research, it may also be a reflection of the level of confidence of the counselors in discussing the interventions they employ. It may be an indication of the counselors' fears of appearing underqualified.

Another pattern that emerged ill this study was the issue of counselor self disclosure. Not one counselor stated that they self disclosed about molest issues to a client. One counselor reported minimal self disclosure: "Almost everything about me is off limits. Almost everything. I disclose that I have pets. If they ask if I'm married, I tell them. If they ask if I have kids and how old, I'll tell them."

Another counselor gave an example of disclosing how she feels to a client: "I tell them, 'You know what? I'm getting upset about this.' Because I think it's important ... I let them know I'm frustrated about this issue." This same counselor later said, "J let them know, 'Look, I have an issue with this. I don't think I agree with this. I don't think I can make a wise decision, so I'm going to ask for a second opinion about this. '"  

Clients who participated in the study reported greater frequency of self disclosure from their counselors, however. One client stated that self disclosure on the counselors' part was therapeutic for him, as it seemed to normalize his experience: "Well, [my current counselor] responded because ... a similar situation happened with [the counselor's] children .... It made me feel better that it could happen to anyone." This same client also stated that his previous counselor had been molested as a child. His previous counselor's life experiences helped him make a connection between his history of sexual abuse and his subsequent substance abuse. He stated, "But [this counselor] was an addict too, for a while, you know? I've come to the conclusion that the molestation caused the drug addiction .... "

Not all clients reported self disclosure from counselors. In fact, one expressed a desire for self disclosure from a previous counselor:

She didn't open up and say anything about her private life, like if anything like that had happened to her .... Well, I assumed she probably didn't share anything with me because she's a counselor; I'm a client. But we're all human beings. I think that women should talk about those things in whatever setting.

 

Should self disclosure be considered a violation of boundaries in the therapeutic relationship? While it may seem concerning upon first examination, there is support for counselor self disclosure in the literature. Barret and Berman (2001) found that therapist self disclosure resulted in clients reporting greater reductions in symptom distress, and clients reported that they liked their counselors more. Overall, therapy was found to be more effective when therapists increased rather than limited their disclosure. Therapist self disclosure can also lead to the client perceiving the therapeutic relationship as more balanced; the client feeling reassured that their experiences are universal; and the client using the therapist as a role model in making changes (Knox, Hess, Peterson, and Hill, 1997).

Overall, the clients seemed satisfied with their treatment at the clinic in question. However, this does not mean that the clinic is without flaw. When the researcher was recruiting clients for this study, it was found that few volunteered to participate in the study. When the researcher approached the counselors about this perceived lack of interest, it was discovered that most of the counselors at the clinic in question did not have clients who had disclosed to them, and therefore had no clients who met the criteria of having disclosed to their counselors, Upon closer examination, the researcher realized that at the beginning of data collection, eight of the twelve counselors from one participating clinic had been employed for less than a year. When the researcher approached two clients in the lobby and asked if there was an interest in interviewing, both agreed, and both met the criteria by having disclosed to previous counselors who had been employed at the agency longer, but that the clients had 110tyet disclosed to their current counselors, One assumption to be made from this finding is that the clients had not worked with their current counselors long enough to have established a feeling of safety in the relationship. In fact, several counselors mentioned the amount of time they have worked with an individual as a factor in the client's disclosure of childhood sexual abuse:  

On several occasions, as I've been counseling regarding anger management or low self esteem. Somewhere along those lines, I strike a nerve or something, and honestly, they are individuals I've worked with for several years. They don't disclose that right away. But I think that's because we've become pretty close as far as the client/counselor relationship goes. They feel confident to disclose certain personal situations.

 

Another counselor expressed a similar point of view:

I've been working here at [this agency] for four years. I can say a third of my caseload I've had for a couple of years, at least two, so once they begin to feel comfortable, they begin to disclose certain information.

 

Another counselor expressed it from the client's perspective, "Because a lot of the clients feel, 'Oh, you're going to be gone in a year, you're going to be gone in six months.'" So they don't open up to you anyway.

And yet another recognized it as a problem of staff turnover:

If they truly want to have some therapy, if this is something they want to deal with, it's not, like, thrown in with everything else, but it's something they want to deal with, I think they should be referred out to someone who's going to be with them for the long haul. And that's usually two or three years.

 

Several counselors mentioned referring clients to other agencies for treatment for trauma issues. Three clients discussed their previous experiences in seeking help. One stated:

I spoke to psychiatrists when I was younger, I mean, the probation department, the parole department. I just ... I could talk circles around them. J didn't really want to tell them. I guess it was the embarrassment and the shame, and I don't think they really cared anyway. It was just a job, I felt.

 

Another client described her experience with a psychiatrist while appealing an SSI decision:

I told her that my dad started molesting me when I was two and that my mom ended up having a nervous breakdown when she walked in and caught him. She was like, ''No your mom must have been crazy already." That might have set [my mother] off, but it was really hard for me. I just wanted to kill her. I did. I was so mad at her, and so hurt. She didn't want to help me or anything. It was like she was against me. Everything I said, she was like, against me.

 

Another client described what happened when she followed up on a referral to Mental Health:

[It was] terrible. The part about getting pushed from one person to the next. OK, talk a little bit, and then I'm going to another person. Then I had to test four weeks in a row because I'm a methadone person. That's just before I can even see a therapist. When you need to talk to somebody, you need to talk now, not four weeks from now.

 

Some clients recanted stories of treatment from other agencies before the researcher began taping the interviews, such was their frustration in dealing with other agencies. One client reported that one county mental health agency told her she was "too healthy" for therapy and facetiously offered her a job. The client was then given a referral from the participating agency's nurse practitioner, and now had an appointment with mental health for later in the month.

Given that the clients interviewed seemed to be satisfied and comfortable with their counseling experiences at the participating agency, it would make sense for the agency to remove the barriers for doing trauma work at the agency. These barriers include: counselors' Jack of confidence in their abilities, lack of clinical supervision, and high staff turnover.

Chapter V - Conclusions and Recommendations

This exploratory study yielded both expected and unexpected results. The study revealed that the counselors in this agency are doing a lot supportive counseling and are utilizing strategies that are clinically appropriate as documented in the literature. The counselors are also doing a lot of work in Helman's first stage of trauma work "Safety," which is not unexpected as creating a safe environment for the client is not limited to trauma work. What is surprising is that the counselors in this study were doing beginning work of the second stage in Herman's model for treatment of trauma, "Remembrance and Mourning." While it is possible for a counselor to harm a client by performing an intervention too early in the therapy, the counselors in this study appear to be erring on the side of caution. According to Briere (1996) a trauma counselor's role is to facilitate access to painful material when the client is able to tolerate it, and to avoid premature exposure to material when it has the potential to overwhelm" (p.l13). Briere calls this delicate balance "the therapeutic window." Just as premature exposure to painful material can harm a patient, "[t]he clinician ... whose focus is based solely on supportive psychotherapy' (i.e, avoiding all psychological exploration) may not ever overwhelm the survivor, but he or she is also unlikely to provide significant assistance in the reduction of abuse-related difficulties" (Briere, 1996, p.114).

The counselors in this study were very much aware of their limitations, and in fact seemed to lack the confidence in their abilities to proceed further with trauma work. In order for the counselors to do further work in trauma, they would need to feel empowered. The agency could assist the counselors in feeling more confident in their abilities by providing training on trauma treatment models and by providing clinical supervision. The agency has regular staff meetings and counselor meetings that allow time for training and supervision, but there is no licensed therapist on staff to provide the supervision. One suggestion would be to recruit a licensed therapist to serve as a consultant for a few hours per month, allowing counselors to present challenging cases on a regular basis.

The other barrier to trauma work being conducted at the agency is that of high counselor turnover. While lack of counselor retention was an unexpected finding, it is nevertheless a significant one. It might behoove the agency in question to examine its hiring practices and actively recruit counselors who are interested in working with a challenging population for a longer period of time, particularly at the clinic that experienced significant turnover in the past year.

There were other patterns that emerged that may warrant further study. One was that of counselor gender and amount of careful exploration of traumatic experiences. While it is not wise to generalize from such a limited sample, it appears that male counselors may be more willing to probe surrounding molest issues.

Another pattern that appeared is that of physical contact between counselor and client. Three counselors admitted using touch as a means of comforting clients, yet all admitted this reluctantly, as though it was somehow crossing a boundary of accepted practice. A training on boundaries in the therapeutic relationship would be an attainable goal, as an accepted rule of thumb is that the counselor should consider whether the behavior in question is for the client's benefit or for the counselor's (Lott,  51 1999). Clinical supervision would also allow counselors to discuss their ambivalence regarding boundaries and prevent counselors from operating in isolation.

While this study revealed that there are barriers to providing treatment for trauma issues at the substance abuse program in question, these barriers are not insurmountable. As the study demonstrated, the benefits to the client of providing the service on site clearly outweigh the disadvantages of referring the client to another agency. Providing clinical supervision and training on this challenging issue may actually playa role in counselor retention, as it would empower counselors and improve their skills, something that many beginning therapists consider in their decisions to work for a particular agency. Furthermore, this study provided a beginning understanding ofthe feasibility and development of trauma treatment approaches in the context of a long term outpatient substance abuse program.  

 

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