Chapter Five – Safety Interventions

Many traumatized youth continue to be at serious risk of victimization, injury, or even death at the time of seeking therapeutic services.

This danger may reflect the risks associated with community violence, gang activity, or prostitution, as well as specific life threat from previous perpetrators, boyfriends, stalkers, parents, or drug dealers/abusers. Adolescent women are at significant risk of being raped or otherwise sexually abused by relatives, partners, and strangers. Gay or transgendered adolescents and racial/ethnic minorities may be assaulted in the context of hate crimes. In addition, the adolescent may be self-destructive; either passively through drug abuse, unsafe sexual practices, or involvement in other risky behaviors; or through more actively suicidal behaviors. The client’s behaviors may increase the chance of HIV or hepatitis C infections, or, in some states, botched abortions. Homeless adolescents especially run a number of these risks, as do others who spend much of their time on the streets. These dangers are present for most adolescents; they escalate dramatically for those who have been previously abused or otherwise traumatized. As noted earlier, childhood maltreatment and other relational traumas are associated with a greater likelihood of subsequent substance abuse, unsafe sexual practices, prostitution, suicidality, and aggression toward others, as well as a greater risk of sexual revictimization.

Given this reality, the clinician must be vigilant to safety issues when working with traumatized youth, and must be prepared to act on safety concerns before and during psychological treatment. In fact, ensuring safety is the first requirement of trauma therapy – and this certainly includes adolescent victims. The primary interventions in this area are presented below.

Suicide Assessment and Prevention

Suicidal thoughts and behaviors are relatively common among abused or traumatized individuals (Tiet, Finney, & Moos, 2006; Zlotnick, Donaldson, Spirito, & Pearlstein, 1997), perhaps especially in the context of ongoing adverse conditions (Molnar, et al., 1998). In some cases, suicidal behaviors are passive, wherein the client engages in high-risk activities and/or fails to protect him or herself in dangerous situations. In other cases, there may be repeated suicide attempts. The therapist is advised to be vigilant to the possibility of suicidal behavior when working with traumatized adolescents, and to perform lethality assessments (e.g., Berman, Jobes, & Silverman, 2006) whenever the client discloses suicidal ideation or significant depressive symptoms. When suicidal lethality (i.e., actual likelihood of a fatal attempt) is assessed to be relatively low, intervention may be limited to discussion of the underlying reasons for considering death, and attempting to problem-solve other, less drastic options. When suicidal lethality is greater, the clinician should modify the treatment plan to include contracting for safety, increased frequency of sessions and/or phone calls, provision of emergency numbers, and increased consultation with peers or supervisors. A psychiatric consultation, medication, or hospitalization also may be indicated.

Child Protection or Law Enforcement Services for Victims of Intra-Familial Abuse

Because most adolescents up to age 18 are considered children by state law, those who are being maltreated by parents or caretakers, other family members, significantly older youth, or other adults are entitled to protection by child welfare or law enforcement agencies. As well, older adolescents victimized by peers have the option of making a police report and seeking protection. Although the client may be opposed to the involvement of child protective services or the police – especially if they have had negative experiences with such officials in the past – the clinician has a legal and ethical duty to report child endangerment to such agencies (Meyers, 2002). Although there may be no duty for the therapist to report to the police victimization by peers close to the client in age, but it is usually a good idea to encourage the client to do so. In the best case, the client’s safety is dramatically increased, and the perpetrator is addressed by the criminal justice system. Occasionally, in the worst case, the client may abruptly terminate his or her relationship with the therapist. More often, however, the clinician can negotiate this process with the adolescent, supporting him or her through the reporting experience, and maintaining an enduring therapeutic relationship.

Assistance in Separating from Gangs

Gang involvement is often a double-edged sword for adolescents living in inner city environments. On one hand, it may offer protection from other gang members, and may provide identity and a context for affiliation with peers (Cummings & Monti, 1993). On the other, it is associated with both engaging in violence and being physically injured or killed by others. Although the clinician almost always wants the client to avoid gang affiliation or to extract him or herself from gang activity, the youth may be quite ambivalent about doing so, and/or may fear retribution from gang members if he or she leaves. The therapist can probably be most helpful by working with the client in a pragmatic, problem-solving sort of way, providing opportunities for the youth to determine what he or she wants, consider his or her best options, and, if the decision is to try to leave the gang, possibly facilitating that process. In some cases, the client can be referred to groups or agencies that assist young people in finding alternatives to gang involvement and that provide a social support system that can substitute for gang affiliation. Often, these organizations also can assist youth who are at risk of becoming gang-involved.

Working with Prostitution Issues

It is not uncommon for homeless (often runaway) adolescents, especially those with histories of childhood sexual, physical, or emotional abuse, to become involved in prostitution (Farley, 2003; Webber, 1991; Widom & Kuhns, 1996; Yates, MacKenzie, Pennbridge, & Cohen, 1988). In some cases, young people are recruited and controlled by a pimp. In others, adolescents may exchange sex for drugs, food, or shelter. Although prostitution is almost always a very negative experience – in many cases requiring the youth to abuse drugs in order to continue it – and is associated with an elevated risk of assault, disease, depression, and posttraumatic stress (Farley, 2003), clinician entreaties that the adolescent just stop such behavior are often less than effective. Instead, the therapist may be most helpful by (a) providing therapeutic support and opportunities to process child abuse-related memories and assumptions, (b) facilitating nonjudgmental exploration of other possible options for survival that are less injurious than prostitution, (c) forming a safe and caring relationship that can be antidotal to the survivor’s other, more detrimental and exploitive relationships with customers, pimps, and other youths caught in prostitution, (d) increasing access to social and medical services, including referral to agencies or shelters specifically created for sexually exploited youth, (e) in some cases, helping to develop safety plans (see below) regarding escape from pimps, and (f) providing assistance with any related substance abuse problems (Schneir, et al., 2007; Thompson, McManus, & Voss, 2006; Yates, Mackenzie, Pennbridge, & Swofford, 1991). Importantly, the clinician may be able to employ these interventions to proactively reduce the chances that the at-risk client will become involved in the sex industry in the first place.

Safety Plans in Cases of Ongoing Child Abuse, Exploitation, or Domestic Violence

If the adolescent currently lives with an abusive parent figure or a physically or sexually abusive partner, or is under the control of some other potentially violent or sexually exploitive person, it is a good idea for the therapist and client to create a “safety plan” (Jordan, Nietzel Walker, & Logan, 2004) – whether or not the client believes it is necessary. Typically, this involves developing a detailed strategy for exiting the home or environment when imminent danger is present (e.g., pre-packed bags, planned escape routes) and finding a new, safer environment, whether it be a friend’s home or a local women’s or homeless shelter. A preplanned escape option allows the youth immediately to enact a well thought-out plan in an emergency, without having to devise one at the last minute. Client-therapist problem-solving activities that involve safety planning are often helpful not only because they increase the survivor’s safety, but also because the process itself is often empowering (Jordan, et al., 2004).

Supporting Safer Sexual Behavior

Childhood abuse and neglect is associated with involvement in unsafe sexual behavior (i.e., involving risk of HIV/AIDS or other serious diseases, as well as revictimization), along with substance use or abuse that may, in turn, lead to risky sexual activities (Koenig, O’Leary, Doll, & Pequenat, 2003). And, obviously, involvement in prostitution may involve sexual behavior that can lead to diseases such as HIV/AIDS. In general, therapeutic interventions in this area involve providing psychoeducation on safer sex practices; increasing self-esteem and a sense of entitlement and self-determination among those coerced into unsafe sexual activities; desensitizing traumatic memories that, when activated, can lead to ongoing substance use; cognitive processing of abuse-related cognitive distortions that lead to reduced self-assertion or self-protection; problem-solving how to accomplish the greatest level of safety even while involved in prostitution; and working with specific substance abuse issues (Briere, 2003; Koenig, et al., 2003). Less effective are unrealistic attempts to push the client to immediately cease all dangerous sexual practices (i.e., repeated insistence that the youth “just say no”), moralistic statements, scare tactics, or repetitive arguments with the client regarding his or her dysfunctional thinking. Such behaviors are especially likely to be unsuccessful when they ask the client to do something that he or she is not able or ready to do, such as resisting sexual demands or aggressive sexual behavior in situations where she or he feels little power to do so.

Referral to Shelters and Programs

A final safety intervention is referral. Because the adolescent’s environment may be dangerous in the ways outlined in this chapter, especially if he or she has no access to safe, reliable, and at least semi-permanent housing, referral to a shelter may be indicated. Depending on the region, larger cities in the United States may have out-reach programs for runaway, homeless, substance addicted, prostitution-involved, unaccompanied immigrant, or physically endangered youth. Not only do such agencies offer a degree of safety, they typically provide specialized interventions for adolescents with these problems. In this regard, it is important that referral options for traumatized adolescents be “youth friendly” and able to deal with the typical problems and issues presented by this population (Schneir, et al., 2007). Unfortunately, funding and governmental support for quality programs is often limited, despite their importance. When available, they can make a serious difference for multiply