The premise of the mandated reporting requirements is straightforward: children who are abused can be protected once a report is made. Often, mandated reporting of child abuse and neglect is a clinician’s only preparation for working with maltreatment. However, when clinicians enter the workforce, they often encounter a different reality.
Despite mandated reporting, children often remain in –or are returned to –unstable, chronically troubled family systems. In fact, intergenerational transmission commonly occurs, and the same damaging behavior patterns are repeated and escalated across multiple generations of caregivers. Yet many treatment models specifically state that treatment is counterindicated in the context of ongoing maltreatment, or before safety is attained. Consequently, family therapists often feel hesitant, underprepared, and ambivalent in providing clinical care to maltreating families.
Because of the realities of child protective services, and the recent mandate to, whenever possible, reunite children with their biological families, research has produced multiple evidence-supported practice model adaptations geared specifically towards working with maltreating families. In addition, several unique models for the most challenging cases (e.g., incestuous families), have been developed as well. These adaptations are based on some of the best-known family treatment approaches, including Cognitive Behavioral Therapy (CBT), Parent-Child Interaction Therapy (PCIT) and MultiSystemic Therapy (MST).
These adapted models are typically based on several foundational assumptions, which treating clinicians should consider as they engage families in treatment:
- Maltreating caregivers are not bad people who intentionally harm their own children. In most cases, these caregivers love and want their children and are doing the best they know how to do (often in challenging, complex circumstances). Most would also do better if they had the skills, resources, and support do so.
- Children love their parents and want to live with them, even in the face of maltreatment. Ultimately, improving family functioning and preventing future abuse without dismantling the family unit is the child’s preferred outcome.
- Families who experience ongoing maltreatment develop relational patterns that enable and reinforce abusive behaviors. Behavioral change is therefore difficult to sustain without addressing the entire family’s relational dynamics.
Beyond these basic assumptions, most treatment models for maltreating families adapt and expand upon the typical components of treatment, including assessment, treatment planning, intervention delivery, and evaluation. In the majority of these treatment models, each family member (including a maltreating adult) is assessed for traumatic stress and treated for these symptoms as part of the family’s treatment plan. For instance, a physically-abusive parent may partake in individualized intervention to address his own history of childhood physical abuse, along with skills-based frustration tolerance and anger management work done in family sessions.
Family maltreatment intervention models also integrate child protective service workers in treatment planning and encourage clinicians to keep these stakeholders appraised of outcomes regularly, so they may evaluate families’ progress more effectively. Most treatment models also include substantial, specialized supervision, and peer-group reflection opportunities. The latter is a particularly important need, since clinicians’ own feelings and life experiences may influence their ability to form a treatment alliance with maltreating caregivers or impact their sense of safety as they visit homes where maltreatment occurs.
Studying these models and applying them to specific cases can make a real difference in the lives of clients and the clinicians working with them. Our workshop at the MAMFT Annual Conference, It’s Not All in the Past: Promoting Harm-Reduction and Building Safety with Abusive, Neglectful, or Impaired Caregivers and Their Children, will address ways to utilize these models with our families.
Annabelle Shestak, M.S., NCC., is the clinician for the Middlesex District Attorney’s Project CARE, an intervention program addressing the needs of children and families in the aftermath of an opioid overdose.
Tsvetina Kamenova is an outpatient clinician and care coordinator who has worked with many families with ongoing abuse or neglect.