Vol. 20, No. 2
April 2015

Partnering with Mental Health Clinicians in Sex Abuse Cases
A Conversation with Ashley Fiore

Ashley Fiore, MSW, LCSW, is the director of trauma-informed practice for Barium Springs, clinical faculty/ consultant for the NC Child Treatment Program, and a clinical consultant for the Partnering for Excellence initiative.

What can DSS social workers do to advocate for evidence-based, trauma-informed treatment?
We really need to insist on this. Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT) clinicians in the NC Child Treatment Program are achieving a 90% success rate in reducing children's trauma symptoms to subclinical levels. That beats the national average! If we knew there was a treatment for a serious physical ailment where 80% or more of the children who got that treatment got much better much faster than children who got treatment as usual, we wouldn't accept that it wasn't available.

Sometimes we hear people say, "But my child likes his current therapist." But if your child had a physician she really liked but only 60% of kids seen by that physician were likely to get better, wouldn't you change doctors? And, the research shows clients actually like their TF-CBT clinicians just as much as their other clinicians.

My dream is that DSS workers would realize how integral they are to linking children to effective services. They are "brokers of service," to use a term from Project BEST in South Carolina. Project BEST talks about brokers identifying whether a family needs mental health services; selecting evidence-informed treatment and skilled providers; monitoring the client's progress and treatment; and taking action if outcomes aren't being met. Of course, to do this you need a working understanding of the model to make sure it's appropriate and that progress is on target.

Part of the challenge is empowering DSS social workers to question mental health providers about the treatment they're providing, and to make sure they are familiar with how clinicians are measuring client outcomes.

What are elements of trauma-informed work for DSS?
Start with safety. Determine what the child and caregiver need for physical and emotional safety. It's also important to include a focus on helping the child develop coping skills to manage symptoms associated with trauma, as well as helping the caregiver understand what's driving the child's behavior and how they can help reduce and manage the child's symptoms.

The National Child Traumatic Stress Network (NCTSN) has developed "12 Core Concepts for Understanding Traumatic Stress Response in Children and Families" (available here: http://bit.ly/1w5oYBs). These are essential building-blocks that underpin whatever model you're using.

Another good resource is by the American Academy of Child and Adolescent Psychiatry. They have parameters for many different types of treatment and specific mental health disorders (available here: http://bit.ly/1vlhQ3l). Social workers should ask clinicians if they are familiar with these parameters, and how their work fits within AACAP's best practice recommendations.

Another critical part of treatment is actually at the very beginning: making sure there is an appropriate assessment. This should include standardized assessment measures, information from at least three sources (child, caregiver, and teacher), a developmentally-appropriate clinical interview from a bio-psycho-social perspective, and consideration of the impact of trauma. Agencies can choose to refer to clinicians for assessments based on whether they see evidence of these things in talking with the clinician or in the clinician's final written assessment.

Once a child is receiving appropriate treatment, how can social workers support the therapeutic goals?

1. Coordinate with mental health providers. If a parent has a DSS meeting that conflicts with a therapy appointment, they have to prioritize the DSS meeting. Let's work together to make sure parents are doing what they need to do, not missing one appointment for another or feeling overwhelmed by multiple requirements.
   
   
2. Recognize that parents must be actively involved, and that the work is very, very hard for them. As a clinician I'm more of a consultant to the parent; the parent is doing the heavy lifting. I tell families, "The child has just 60 or 90 minutes a week with me. The rest of the time you will be their coach, helping them practice skills and create new, positive associations." It is helpful to actually write into the case plan "parent and child will successfully complete all of the components of treatment." It's sometimes important to have that leverage to complete the treatment successfully, with parents remaining engaged.
   
   
3. Call and check with the provider. Ask where we are in the model. Ask what we're seeing. A good clinician is spending time doing case management for children involved in the child welfare system, and should be accessible to you.
   
   
4. Be cautious about asking for visitation or custody recommendations. That's not the therapist's role. I understand completely why it happens. Sometimes the judge wants to know what the therapist thinks. But giving a recommendation impacts the therapist's ability to create a relationship with the caregiver and to serve as a coach and cheerleader for the parent. Therapists can't be in a dual role of also deciding the outcome of the family's case. Clinicians can describe what a child needs to thrive and optimize their progress, based on the research on trauma, and on what they're seeing. But the therapist's focus needs to be on symptom reduction.

How can DSS social workers most effectively communicate with clinicians regarding the child's DSS and clinical plans?
We need to know each other's roles and limitations. A lot of animosity is due to misunderstanding. We need to appreciate that different viewpoints give us a broader perspective and allow us to be more helpful as a group than we could be individually. We all need to pick up the phone more often.

For their part, DSS workers should be sure they know what the therapeutic goals are for the child, how the therapist is measuring progress, and whether the child is making progress.

How can social workers promote psychological as well as physical safety for children who have been sexually abused?
Make a careful assessment and plan for visitation. A child should not be around the person who sexually abused them until both have received effective treatment and are clear about who is responsible for the abuse.

Even after this, we still need to think very carefully about who is supervising visits. How do we vet those people? What support and training do they have? Can they recognize certain looks or subtle threats an offender might give? Are we putting a parent who is a previous victim in the position of having to keep the child safe? If I'm a child and I've seen my mother unable to keep herself safe, how can I be sure she will keep me safe?

It's important to create rules for visits with a family member who can't admit wrongdoing, who minimizes the offender's responsibility, or who simply doesn't believe it happened. For example, a grandma may not believe her son did anything. Rules might include the following:

• Focus on the present: no talking about the future until things are known;
• Talk to parents about looks and other threatening gestures that will cause the visit to be ended early;
• Teach parents how to express their feelings and validate their children's feelings without making promises.

At the same time, I think mental health providers have been slow to accept the fact that most families ultimately reunify. It's far better this happens in a therapeutic way that's planned and out in the open. I see this as final phase of treatment, after you've resolved the trauma symptoms. This requires the person treating child and the person treating the adult or sexually aggressive youth to collaborate closely. Too often clinicians stay in silos, which may unwittingly model avoidance. This is an essential phase that we need to consider after trauma symptoms have resolved.