Sunday, November 27, 2011

What if... A Post-Penn State Fantasy About the Prevention of Child Sexual Abuse

Here is the second article written by Dr. Steve Brown

by Steve Brown, Traumatic Stress Institute

Roxanne is a fictitious 27-year-old mother of six-year-old Sarah. A single mom since Sarah’s birth, Roxanne has finally found the “love of her life”-– 35-year-old Justin. He’s got a steady job, only drinks on weekends, and seems to just adore Sarah. He loves playing with her and even has been willing to babysit whenever Roxanne needs a girls’ night out. Quite frankly, Justin almost seems too good to be true.

Six months ago, Roxanne and Justin were ready to take their relationship to the next level so they moved in together. Justin pays most of the rent and gas so things are looking up financially for Roxanne. They have even talked about marriage, prompting lots of chatter between Roxanne and her girlfriends about when Justin was going to “pop the question.”

Sarah was SO happy when Justin moved in. She’s never really known her father and always felt jealous seeing her best friend playing with her dad in their front yard. She secretly hoped her mom and Justin would get married.

Three weeks ago, Roxanne grew concerned when Sarah started to wet her bed, something she had not done for years. Sarah also seemed especially clingy at bedtime, not wanting to say goodnight or to go into her bedroom alone. Roxanne needed to lay down with her at night in order to get her to go to sleep.

Once, when Roxanne went to lay down with Sarah, Sarah’s bed smelled like cigarette smoke. She didn’t smoke, only Justin did. In the morning she asked Justin if he had been in Sarah’s room and he shook his head, looking at her as if she was crazy. Another night, Justin came home late and Roxanne happened to wake up and hear the door to Sarah’s room creak. She thought it was strange because Sarah almost never gets up to go to the bathroom in the middle of the night. A third time, Roxanne found Justin’s shoes underneath Sarah’s bed -- “That’s strange," Roxanne thought, “well, maybe Sarah was just playing her make-believe games and used Justin’s shoes.”

In a post-Penn State sex scandal world, maybe, just maybe, the following would transpire.

Like millions of other Americans, Roxanne has been riveted by the news about the alleged sex abuse by Jerry Sandusky at Penn State. On CNN’s Late Night with Anderson Cooper, she sees an expert talk about how most people think of sex abusers as creepy perverts, lurking around playgrounds, but in fact over 70 percent of sexual abusers are known, and often loved, by the children they abuse. They point out that true prevention of sex abuse will only happen when mothers, grandmothers, neighbors are alert to the possible signs of troubling behavior by their boyfriends, uncles, the next door neighbors. They need to pay attention to their gut feelings when they think something isn’t right about the sexual behavior of the person they know. It’s hard to face the possibility that someone you’ve trusted may be hurting a child, even harder to speak up.

Suddenly, Roxanne flashed to the smell of cigarette smoke in Sarah’s bed – “why on earth would Justin be in Sarah’s bedroom without me knowing about it. There must be an explanation. Maybe he was just tucking her in that night and I didn’t know about it. Maybe I’ll ask Sarah.”

When Roxanne asks Sarah, Sarah looks away and doesn’t say anything. When Roxanne asks her again, “Has Justin ever come into your room at night?” she quietly says, “no.”

“This isn’t possible,” Roxanne thinks, “Justin is SO good with Sarah. He adores her and she seems to like spending time with him. There’s no way. Finally, I’ve found the man of my dreams. Everything is working out. I might even get married. I love Justin. But, I can’t stop thinking about this.”

The next night Anderson Cooper reports:

“One of the most disturbing parts of the Penn State sex abuse scandal is how many people likely either had direct information or suspected Mr. Sandusky of abuse and failed to come forward and speak up on behalf of the victims. They were passive bystanders, not active ones. Think how many victims could have been spared if JUST one of those adults had come forward and had the courage to not let it rest.”

Roxanne suddenly feels like she’s been kicked in the stomach. “How many times now have I had this yucky feeling about Justin. I keep wanting to put it out of my mind. WHY does it keep nagging at me? All those people at Penn State, they looked the other way. Am I looking the other way? It CAN’T be possible, but maybe…I have to talk with someone.”

The next day Roxanne has lunch with her girlfriend. “Can I talk to you about something? This is going to sound so strange, but I just can’t get it out of my head…” and she goes on to tell her friend about what she has observed ending with “I’m sure it’s nothing, right?” Her friend looks stunned, “I CAN’T believe you’re saying this. Justin has always struck me as a little creepy. I never told you this, but I saw him sort of hitting on a 13 year-old girl. I didn’t think anything of it, but it was WEIRD. Once, when I was at your house, I heard him tell Sarah that her butt was cute in her tight jeans. I didn’t think it was anything so I didn’t tell you. But, it did seem really inappropriate. ”

Two days later, Justin came home again in the middle of the night. Roxanne stayed awake this time. Again, that creak of Sarah’s door. When Roxanne burst into the room, she saw Justin lying next to Sarah on her bed. He immediately stood up and yelled, “What the hell are you doing here? I was just tucking Sarah in.” Justin had clearly been drinking. Roxanne threatened to call the police unless Justin left immediately.

When she talked to Sarah about what had happened, Sarah said that Justin had been coming into her room numerous days in the past month. He always woke her up, lay down next to her, and talked about how she was so special. He always had alcohol on his breathe. He’d kiss her face and rub her back. When Roxanne asked if he had touched her on her private parts, she said “no”, but she hated when he came in. She couldn’t fall asleep at night thinking it might happen again. Roxanne said, “Sweetie, I’m so sorry this happened. He will never do that again to you. I promise. I swear.”

As Roxanne sat awake in bed that night, she could barely contain her rage. "But, at least I caught it before anything really bad happened. It could have been like those boys at Penn State. Thank God I trusted my gut. Thank God I talked with someone. Thank God I spoke up!!!”

Now THEN we’d be making progress on preventing sexual abuse of children.

Sunday, November 20, 2011

Preventing and Reporting Child Abuse: The Questions Raised by the Penn State Scandal

This excellent article was written by my colleague Steve Brown, PsyD.

Last week, a Pennsylvania Grand Jury indicted former Penn State defensive coordinator Jerry Sandusky for sexually abusing eight boys over the course of a 15-year period. The indictment also charged two top university officials with perjury and failure to report what they knew about the allegations. The indictment has kicked off a firestorm of media attention both in the sports world and the US at large. On November 9th, the Penn State Board of Trustees fired legendary football coach Joe Paterno and Penn State President Graham Spanier. Allegedly, a graduate assistant told Paterno that he observed Sandusky abusing one of the boys. Paterno reported this to Athletic Director Tim Curley although did not follow up later on the matter or alert legal authorities himself. The indictment stated that President Spanier was made aware of the incident reported to Paterno as well.

In any particular abuse situation there is an abuser, a victim, and (almost always) bystanders. This is true in bullying, street violence, as well as child sexual abuse. One of the most important questions that the Penn State situation, and cases like it, raise is -- what is it about the nature of intimate sexual violence that stops so many bystanders from taking action when they either have direct information that abuse has occurred or, more commonly, just an inkling that something might not be right.

It is true that men like Mr. Sandusky can often be well-regarded, upstanding citizens, involved in the community, even loved as a role-model by many. However, it is ALSO true, as has come out in the press, that numerous people had direct knowledge of, and even directly witnessed, Mr. Sandusky sexually abusing boys. Despite this knowledge, they were passive bystanders, not active ones. If any one of these adults took appropriate action to report this to the proper legal authorities, maybe the abuse would have ended with one or two boys rather than eight. Maybe the victims would have been given help and protection.

While some adults in this situation had direct knowledge of the abuse, I'm guessing there are likely many others who had troubling gut feelings about Mr. Sandusky --family, neighbors, players, coaches, etc. Many such people are now wracking their brains about what signs they might have missed, why didn’t they trust their gut, and, most importantly, what prevented them from coming forward. These are good and important questions. Even Joe Paterno, whose Penn State football team proudly extolled a reputation for being “squeaky clean” and whose motto was “success with honor,” could not see clear to act on his moral responsibility to protect current and future victims. It is especially disturbing that those with direct knowledge could not muster the resolve to actively speak out.

However, for all of us, there is this critical question -- WHAT prevents us from speaking out, not ignoring what we see, paying attention to these gut feelings, checking them out, talking with a friend or colleague about them, and ultimately taking action to alert the proper authorities?

I think there are complicated answers to this question.

Much of it relates to our societal denial about the reality of child sexual abuse. We SO want sex abuse to be about the creepy pervert, the stranger who abducts and molests our kids. Let’s just put them all on sex offender registries, attach GPS devices to their ankles and we’ll be okay. We DON’T want to admit that 90 percent of sex abuse is committed by people known by the victim and the family – our brothers, uncles, fathers, stepdads, and…yes…coaches.

If we do speak up, we are intruding on the privacy of the hallowed family --whether it be a family unit or the Penn State family. Sometimes, we don't know what signs to pay attention to in these men. Even if we do, we don't want to get involved: “I told my supervisor. If they don’t act, it must not be that big a deal. Anyway, if anything happens, it’s on them, not me.”

We especially don't want to get involved when there are powerful people and institutions involved. When those institutions have “squeaky clean” images to uphold, we don’t want to be responsible for tarnishing that image. If we do raise our concerns, we risk social rejection. We also need to have some comfort with our feelings related to the shrouded area of sexuality and the language of sex to get involved and speak up. If we speak up (as an adult bystander or a victim), it is HIGHLY likely that things will get worse in the short term although hopefully better in the long term.

Many people, playing Monday morning quarterback, are outraged about the fact that bystanders didn't speak up (and we should be outraged by this case), but this does NOT recognize the reality of the barriers listed above. Until we grapple as a society with these many barriers, we will make limited progress on prevention.

Child sexual abuse prevention, led by organizations such as Stop It Now!, seeks to answer exactly these questions – how do we help adult bystanders recognize the signs of sexual abuse, talk with others about what they are seeing, and find the courage and words to speak up. Unlike Penn State, most often it is a wife speaking up about (or to) her husband whom she sees repeatedly coming out of their daughters’ bedroom in the middle of the night; a neighbor speaking up about (or to) a beloved neighbor who frequently has boys coming in and out of his house; an adult niece speaking up about (or to) a great uncle who always wants to play video games in the basement alone with a 10 year-old relative.

This is not an easy subject to raise when the abuser is the primary earner for the family; when he is well-loved, even by the son or daughter he is abusing; when he is the founder of organizations for vulnerable kids which do a lot of good; when speaking up means a crisis will ensue.

To prevent sexual abuse, we must ALL struggle with these questions. Perhaps the Penn State situation will move us a little closer to speaking up as ACTIVE bystanders, not passive ones, looking out for the well-being of our children and those who cannot speak for themselves

Sunday, November 13, 2011

Connecting Theory to Action

This is a long post that summarizes the way that the Restorative Approach provides a bridge between theory and action in treatment programs.

The Restorative Approach translates what modern science has learned about trauma and how it affects the brain into specific strategies for daily interactions with the children. The following points summarize the connections between theory and daily actions.

The Restorative Approach recognizes that a traumatized child’s brain is different, in that the prefrontal cortex is less developed. Because of that trauma-related difference, the child is easily overwhelmed by emotions. In treatment programs using the Restorative Approach, staff members understand that they will have to act as the child’s prefrontal cortex for awhile, teaching problem-solving rather than punishing a child for seeming to ‘choose’ to act out emotionally when the child is doing the best he can. The staff members’ brain building tasks include helping the child with selective attention, working memory, self-observation, and response inhibition. Further, the staff respond to the child’s emotional dysregulation with calming techniques rather than with thinking interventions.

A traumatized child typically has a strong, even over-developed, response to any situation perceived as dangerous. Using the Restorative Approach, staff members aim to soothe the child whose emotions are blowing up, to reassure him or her rather than get into a power struggle. The last thing a staff member trying to help an emotionally dysregulated child would do is back him or her into a corner. Instead, staff use soothing techniques when the child is upset. They teach uses of emotions and how emotions contain information, and actively teach self soothing. The staff provide and identify safety. One part of this is to talk before doing something, and to provide predictability. The program uses crisis kits and crisis prevention plans. Staff are aware that child will notice everything that they do, how they treat each other, their tone of voice, and their expressions.

Because of their focus on danger, the child may miss a large part of what goes on around them. Staff will have to coax child to have fun and point out joys in life.

Traumatic events that are experienced prior to the acquisition of language may return to the child as flashbacks, as though he were reliving, not remembering, the experience. At times the child may dissociate to manage the pain of his experience. Staff can teach grounding techniques that return the child to the present.

The physical underdevelopment of the child’s brain results in him having more difficulty accessing his verbal memory. Therefore, staff do not rely on verbal planning alone, and whenever possible use multi-model interventions such as charts, pictures, art, dance and music.

The child whose life has been unpredictable has confused, few or no regular bodily rhythms. Staff help develop bodily rhythms by maintaining predictable structures and offering rhythmic activities such as yoga and dance. The child also has an under-developed ability to sort out social cues, so staff are clear in communication and use simple language. They teach social interpretation through movies, books, etc.

Lake of early reliable care combined with trauma and attachment disruptions result in a child whose connection with his own body has not been reliably established. Therefore, he may have difficulty regulating their body functions. Staff can help through offering repetitive, rhythmic, rewarding activities to rebuild the lower brain, the part that controls the body. The child may have difficulty sleeping, so staff will not punish bed time problems, but instead look for ways to help child relax such as night light, reading, or music. Staff will therefore handle hygiene issues with sensitivity and understanding of complexity (symptoms are adaptations), not with consequences, and will find opportunities to teach healthy sexuality.

Because the child has had less attuned interactions, his brain is less integrated and he has more trouble with generalization from one situation to another. Staff therefore make connections explicit and specifically make comparisons between various aspects of life, distinguishing past from present. They give the child opportunities to practice new skills in many arenas and settings.

Children who grow up with neglect and trauma are not taught how to recognize or name emotions, so it is up to treaters to teach them the names of emotions and model healthy emotion. This includes the recognition of bodily sensations of emotions. The child may experience his emotions as moving from extremely aroused to extremely shut down quickly with no apparent rational. Staff can help child develop awareness of his own emotions and their stages, and develop tactics for each stage.

The hallmark of trauma is the victim’s lack of control. He cannot influence what is happening to him, and he is used to fulfill someone else’s needs. He is not treated like a person. After repeated exposure this powerlessness generalizes to all situations. The child learns that no effective action is possible in their life. Therefore it is important that treatment systems do not replicate this experience, and that they allow many opportunities for active participation in decisions involving the youth. They can also respond to problems by guiding the youth to fix damage they have created and repair relationships they have hurt. Because of this previous lack of control, the child may value control above all else. The program can give child control whenever possible, collaborate with him, and focus on him learning to control himself as opposed to staff controlling his behavior. Because control is so important, and lack of control is associated with victimization, the child may cover up vulnerable feelings such as fear and sadness. Staff can create safety to allow the child to share vulnerable feelings, and model having vulnerable feelings in a healthy way.

The child believes that everything that has happened to him is his own fault. To heal he must develop a sense of safety in which he can share what he finds shameful and receive compassion. Staff can also point out his strengths and achievements.

The child’s experiences have taught him not to trust adults. Programs can provide a different experience by being trustworthy, and by emphasizing trustworthy relationships. They can point out how present relationships are different from past relationships. The child expects the worst in relationships, and so may push people away. Staff understand the adaptive aspect of the child pushing the adult away, stay committed, and don’t pull back. They verbalize and validate the child’s fears.

The relationships in the child’s life have often violated his boundaries, involving him in adult problems and activities, requiring him to perform tasks beyond his abilities, causing him to be the caretaker of adults. Therefore the child is uncertain about boundaries and tests them. Staff can maintain firm yet flexible safe boundaries, be aware of the complexity of boundaries in child’s life, discuss boundary issues openly with each other and with children, and also seek supervision around these issues to identify their own reactions so that they don’t interfere with the work.

The child has not been taught how to handle problems in relationships. When he has had relationship difficulties, the other person has often just disappeared. He may have seen adults handle problems with drinking, drug use or violence. Staff has the opportunity to provide relationships that stick with the child. They can model relationship skills, speak from their hearts and share their own modulated emotional reactions. They can always address the relationship aspects of events, provide paths to work through relationship difficulties, and actively teach social skills. Since he does not trust others, the child may have trouble asking directly for what he wants. Staff can encourage direct communication and practice and model skills of making requests. They can say yes when possible.

Similarly, the child has not learned how to handle something going wrong without making it worse. Staff can teach distraction and calming techniques, help the child develop a list of tactics to improve situation, offer child alternatives, not consequences, when he is becoming agitated. and develop with the child a list of many positive coping tactics for handling pain.

Because of both his past and present situations, the child often feels hopeless. Staff can help through pointing out skills and gains. Also, they can teach and support the child in advocating for himself.

Working with children who have survived trauma, neglect and attachment disruptions caused strong reactions in all treaters. The trauma informed program is aware of vicarious traumatization, and imbeds in daily operations opportunities to discuss the effects of the work, care for one’s self and other team members, and encourages practices which promote vicarious transformation.

Thursday, November 03, 2011

Carter Symposium on Mental Health Policy

I had a wonderful time attending the Carter Symposium. For me, the experience was composed of many parts. These included the inspiration of Mrs. Carter herself; the many interesting and intelligent people I met; some inspiring people I already knew and heard again; and the facility itself and the professional and efficient way the conference was run. My most overwhelming impression was that so many people in so many widely differing areas of the helping professions are transforming how they provide services based on our increasing knowledge about trauma. It may turn out that research about trauma, its effects and how healing takes place will be the revolution of our century!

The first keynote conversations were about the National Child Traumatic Stress Network ( In addition to all the wonderful treatment and service provision projects NCSTN has facilitated, they are collecting significant data about all the clients served and all the outcomes of various forms of treatment. This rich national data set gives us all sorts of opportunities to learn about the experiences and symptoms of the children seeking help, and most importantly, what helps them and their families.

Following the speakers was a Poster Session. I had the Traumatic Stress Institute poster on display and enjoyed many conversations with my fellow participants. Next to me was a friend from Connecticut, Jason Lang from the Center for Effective Practice, whose poster describes the Connecticut implementation of TF CBT.

After the delicious dinner, Christine James-Brown, the CEO of the CWLA spoke.

On the second day, the first speaker and panel addressed the increasing awareness of trauma in the child welfare system. The plenary speaker was Brian Samuels, M.P.P. Commissioner, Administration on Children, Youth and Families, US Department of Health and Human Services. He emphasized that the goal of his department was well being, not just permanency. He presented interesting statistics that showed that children who achieve permanency or are adopted do not in fact get better afterwards. Their symptoms continue to get worse. This speaks to the need for specialized treatment services for older adoptive children, and those adopted out of foster care. Speakers then presented several specific interventions for the child welfare population.

Particularly interesting was Dr. Sandra Bloom who presented her theories of how organizations themselves are living organisms, and as such experience trauma and exhibit all the trauma symptoms. She described the Sanctuary Model as a way to heal from this trauma.

The next set of speakers addressed the increasing awareness of the role of trauma in the Juvenile Justice System. The plenary speaker was another Connecticut representative, Julian Ford, PhD. He described his intervention, TARGET. The moderator and the following speakers acknowledged that the Juvenile Justice system is just beginning to implement any trauma informed practices, and that there is resistance. Judge Steven Teske, JD was especially articulate on the importance of educating judges and involving them in the solutions.

This was followed by concurrent sessions. I attended the session about Care Giving and Parenting. I heard two excellent presentations. Patricia Barron, M.A. spoke about helping military families who have a parent deployed away from home, and included excellent resources for agencies wanting to help. Jeanne Miranda, M.P.A. described a specialized intervention she and her team were developing at UCLA to treat children who have been adopted from the foster care system. Both speakers combined personal experience with professional knowledge: Ms. Barron herself is in a military family, and Ms. Miranda is an adopted mother of children from the foster care system.

I have to report that on the way back from these sessions I personally met and spoke to Mrs. Carter, and followed up by giving her my TSI materials. That was so moving! She is a true heroine. She is 84 and had just returned from observing an election in Tunisia (I think that was where it was).

The summation focused on what we can personally do with the material we learned, how we can bring it back to our own practice. It was very inspiring, especially the concluding remarks by Mrs. Carter.

This was all held in a beautiful location, which is also the home of the Carter museum. The staff and volunteers were so helpful, the food was delicious and the conference was very well organized. All in all, an excellent experience.