By: Elizabeth Leuthold, MEd and Alejandra Sequeira, MEd
Access to mental health services for children with traumatic experiences is a longstanding challenge (Burns et al., 2004). Children, defined as youth under age 18, are a vulnerable population (U.S. Department of Health and Human Services [HHS], 2016). In 2014 alone, Child Protective Services (CPS) received an estimated 3.6 million reports of suspected child abuse, which resulted in the identification of 702,000 child abuse victims (HHS, 2016). More broadly, Copeland, Keeler, Angold, and Costello (2007) reported 68% of all children in the United States have experienced at least one potentially traumatic event (e.g., violent or life-threatening situations, natural disasters) and half of these children have experienced multiple traumatic events.
Experiencing childhood trauma can have a severe impact on development (Finkelhor, Ormrod, & Turner, 2009). Childhood traumas are strongly correlated with an increased likelihood of poor mental health throughout the lifespan (van der Kolk, 2005), and traumatized children may exhibit numerous emotional and behavioral problems (Price et al., 2013). Children can struggle with a wide range of reactions to trauma including fear, anxiety, difficulties trusting others, and sexual maladjustment (Finkelhor et al., 2009). These responses may be reflected in a child’s over-controlled behaviors such as rigid, inflexible rituals, or, conversely, under-controlled behaviors such as aggression, self-injury, and avoidance reactions (Price et al., 2013). As such, successfully treating survivors of child abuse is an important goal. The current paper aims to present caregiver involvement in therapy as a beneficial way to enhance trauma work with child clients. The authors will provide case examples to illustrate the importance of such involvement as well as offer practical suggestions for clinicians to foster such involvement.
Caregiver Involvement in Therapy
Children are not islands to themselves; rather, they exist within their family systems. For this reason, active caregiver involvement from non-perpetrator caregivers should be included in any child-focused treatment (Kazdin & Weiss, 1998). Research suggests that children whose caregivers are actively involved tend to exhibit behaviors that include homework completion, efforts outside of treatment, and progression towards goals (Gopalan et al., 2010). Apart from caregiver training or family therapy, however, caregiver involvement in child-focused therapies has been largely ignored (Duhig et al., 2002).
Premature termination from psychotherapy with children is common, with 40-60% of families missing appointments and terminating services before the course of treatment is completed (Gopalan et al., 2010; Nock & Ferriter, 2005). Reasons for premature termination include caregivers’ lack of faith in the therapeutic process (Nock & Kazdin, 2001), and caregivers’ attitudes, emotions, and beliefs—specifically guilt and self-blaming (Clements, 2004). Other barriers to parental involvement in their child’s treatment include distance from treatment facility, lack of resources, poor interactions with staff, limited opportunities for involvement, and lack of knowledge of ways to become involved (Kruzich, Jivanjee, Robinson, & Friesen. 2014). These findings suggest there are changes needed within the field in order to increase rates of caregiver involvement.
Caregiver involvement is crucial as the success of children’s treatments largely depends on their caregivers’ belief in the therapeutic process (Radunovich & Wiens, 2012). Child-focused treatments could benefit from making the caregiver the agent of change (Kruzich et al., 2014; Nock & Ferriter, 2005). Modifying caregivers’ expectancies about their child’s treatment can help caregivers to become more involved, which can increase attendance and treatment adherence (Nock & Kazdin, 2001). For example, Stolberg and Mahler (1994) found that caregiver ratings of their child’s therapeutic gains are associated with level of involvement in treatment. Involved caregivers knew more intimate details about their child’s treatment and could provide more accurate information about their child’s internal state than those who were uninvolved (Stolberg & Mahler, 1994).
One way clinicians can begin incorporating caregivers is through collaboration to foster participation in the therapeutic process (Gopalan et al., 2010). Discussed below are two examples of how one author of the current paper provided trauma-focused cognitive behavioral therapy (TF-CBT; Cohen, Mannarino, & Deblinger, 2006) to two clients at a Child Advocacy Center. TF-CBT includes parental participation, and studies show that parental support throughout TF-CBT treatment is associated with more positive outcomes (Cohen, Mannarino, & Murry, 2011). Regrettably, caregiver involvement is not always possible, as demonstrated in these cases. A personal reflection of working with these two different families is also included.
Case Examples: A Contrast of Two Clients
Kate, a 14-year-old girl and survivor of child sexual abuse, was raised by a single mother. Her mother was invested in Kate’s counseling and treatment. She sat in the waiting room while Kate attended weekly counseling sessions, and developed a friendly rapport with Kate’s counselor. She often visited with her daughter’s counselor before and after session to check on Kate’s progress. Her belief in the therapeutic process benefitted her daughter, as she encouraged Kate to continue treatment despite difficulties surrounding trauma processing. As Kate went through the TF-CBT, she became increasingly interested in sharing her trauma narrative with her mother. She expressed that, while it would be difficult, it was an important part of her healing process. Kate and her mom had a joint counseling session in which Kate shared her trauma narrative with her mother, expressed her emotions, and formed a collaborative treatment plan. Kate successfully finished TF-CBT and her counselor believed that she terminated with the security of a wonderful support system to empower her beyond her treatment.
Unfortunately, not every family is like Kate’s. Madison is a 15-year old girl who lives with her aunt and uncle. CPS placed her in their care after confirming reports of physical and sexual abuse by Madison’s grandfather. Her aunt and uncle attended the intake session, but subsequently relied on the family’s babysitter to transport Madison to treatment. They were not involved in her therapy and had no relationship with her counselor. Madison struggled to attend therapy on a regular basis and would sometimes miss appointments when her babysitter and aunt did not coordinate schedules. This created a treatment obstacle and made it difficult to maintain rapport with her counselor.
Madison’s counselor attempted to engage her family by calling her aunt regularly to discuss treatment progression. Madison elected not to share her trauma narrative with her aunt and uncle, preferring to keep it private. While Madison did eventually finish the course of her TF-CBT treatment, her counselor was concerned Madison would not be comfortable discussing her emotions and reactions to trauma with her aunt or uncle in the future. While her counselor suggested continued therapy sessions to address future safety concerns and plans, her aunt opted to terminate due to upcoming school commitments. The counselor was left wondering what would have helped Madison feel more comfortable sharing her story with her caregivers.
Benefits of Parental Involvement In Case Examples
Reflecting on Kate’s story, it feels inspiring to see caregivers become a part of a child’s recovery, working in tandem to help a child recover from a traumatic event. Conversely, it is heartbreaking to consider cases like Madison’s in which children meet basic therapy milestones but do not flourish in treatment. A strong sense of caregiver involvement and support could potentially remedy such situations. These case examples illustrate that while engaging caregivers is difficult, it is an incredibly vital part of therapy.
Counselors can include caregivers in various ways. For instance, Madison’s counselor contacted her caregiver regularly via telephone to update her on treatment. In Kate’s case, the counselor established rapport with Kate’s mother visiting before sessions and checking on Kate’s progress. It is essential that clinicians invest in a relationship with caregivers and inform the child client why this relationship is important. For example, discussing the importance of active parental involvement and limits of confidentiality with the youth client can help them understand why parental involvement is essential, which can help clinicians overcome any reluctance the youth has regarding this process. If clinically appropriate, meeting separately with caregivers to discuss therapeutic processes, gains, and risks before therapy even begins can set a foundation for a positive working relationship between the caregivers and counselor. Having regular discussions with caregivers at the beginning of each session can maintain the relationship. When caregivers trust the therapist and have a personal connection, they may become more invested in the process. Clinicians could spend more time detailing a child’s therapeutic progress, as measured by assessments, with caregivers to demonstrate the impact of therapy. Also, joint meetings with the caregivers and the child can help facilitate familial discussions about therapy, coping, and recovery.
With a therapeutic relationship in place, clinicians can train caregivers on how to best support their children. Similarly, caregiver psychoeducation groups can illustrate caregivers’ crucial role in their child’s treatment and give them practical suggestions on how to become involved. As one size does not fit all, clinicians should tailor their caregiver involvement interventions to each specific child and situation (Gopalan et al., 2010). For instance, including Kate’s mother in a joint counseling session for Kate to discuss her trauma narrative matched Kate’s need for her mother to understand her experience as part of her healing process. This same technique was not a good fit for Madison and her therapeutic needs, as she was uncomfortable sharing with her caregivers. Clinician efforts to develop a relationship with caregivers and establish “buy-in” for their children’s treatment can ensure caregiver commitment to participate in therapy. It can also help establish a foundation from which clinicians can teach parents effective ways to engage with their children outside of session to further their therapy goals.
When clinicians strive to incorporate caregivers, they include the child’s support system in treatment and increase the potential for success (Nock & Ferriter, 2005). Trained counselors can make a world of difference by providing a safe environment and evidence-based interventions to children who have experienced trauma; these efforts can be enhanced and have more influential effects when caregivers further therapeutic growth outside the therapy room.
Elizabeth Leuthold has a Master’s degree in Educational Psychology and is currently pursuing her doctorate in Counseling Psychology at Texas A&M University. She has experience working with PTSD with both child and adult populations, including veterans as well as children who have experienced physical and sexual abuse. Her main clinical and research interests include childhood trauma and PTSD, especially in addressing health disparities with this population in rural, underserved areas.
Alejandra Sequeira is a fifth year counseling psychology doctoral candidate at Texas A&M University. She has her Masters of Education in Educational Psychology from Texas A&M University. She is currently completing an APA accredited pre-doctoral internship at the Cherokee Health Systems.
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Elizabeth Leuthold holds a Master’s degree in Educational Psychology and is currently pursuing her doctorate in Counseling Psychology at Texas A&M University. She has experience working with PTSD in both child and adult populations, including veterans and children who have experienced physical and sexual abuse. Her clinical and research interests include childhood trauma and PTSD, particularly addressing health disparities with these populations in rural, underserved areas.
Alejandra Sequeira holds a Master’s of Education degree in Educational Psychology and is a fifth year Counseling Psychology doctoral candidate at Texas A&M University. She is currently completing an APA-accredited pre-doctoral internship at the Cherokee Health Systems.