Healing the Incest Wound, originally published in 1988, was a landmark achievement in the modern era of trauma psychiatry and psychology. Christine Courtois, PhD is one of the pioneers who helped rediscover the long-neglected effects of pandemic childhood sexual abuse and to introduce treatment models that could help incest victims reclaim their lives. The original book became a classic, providing guidance and support to countless clinicians during a time when there was a profound dearth of information on the subject of incest. Now, more than 20 years later, Courtois has succeeding in integrating the explosion of knowledge and expertise developed over the intervening years into a comprehensive and authoritative second edition. In the original edition, she relied largely on her own experience and expertise along with the relatively few published papers concerning sexual abuse and posttraumatic responses. In this current edition, she has supported her observations with the empirical evidence and clinical wisdom of hundreds of publications. Courtois has heightened the complexity of her thinking with the expertise of other professionals in the trauma field – many of whom based their efforts on her earlier work.
As in the original edition, Healing the Incest Wound is divided into three sections. Section I provides a meticulous review of the characteristics, categories, epidemiology and dynamics of incest. Section II describes the many and varied aftereffects of incest. Perhaps most helpful to practitioners is Section III that comprehensively details the treatment process: the philosophy, goals, sequencing, diagnostic considerations and psychotherapeutic processes, as well as specifics concerning treatment modalities and special populations. This second edition is nearly twice length of the original. Quality should not be judged by quantity, but the additions and elaborations in this edition provide information that is timely, relevant and useful.
It is testament to the quality of the original edition of Healing the Incest Wound that Courtois’ observations and understanding of the nature, effects and treatment of sexual abuse have held up extremely well. For example, in the 1988 original edition, based on nascent research and anecdotal experiences in the trauma field, Courtois speculated about the association of sexual abuse with deficits in physiologic, developmental and psychological functioning. In this new edition, there is a wealth of data and findings that support these negative effects of sexual about in virtually all domains of human functioning. The new edition also helps to integrate many diverse approaches to treatment that have been developed in the past decades including feminist, traumatic stress, developmental/attachment, relational, and loss/bereavement perspectives, which can be of enormous assistance to clinicians in using effective and eclectic approaches in their treatment of sexual abuse survivors.
In the current edition of Healing the Incest Wound, Courtois describes the stage-oriented treatment model for complex PTSD. Developed in the 1990s, this model of treatment proposed that effective treatment for severely and chronically abused individuals requites an early stage of safety and stabilization along with building functional and relational skills prior to active work on the traumatic events themselves. Courtois offers a clear and concise description for stage-oriented treatment for complex PTSD, a model which has become the standard of care for severely traumatized patients. Throughout the remainder of the book, she further elaborates on the issues that will allow clinicians to learn about how to provide skillful, effective and helpful care to some of their most challenging patients. Consistent with developments in the trauma field, the current edition offers a new focus on both the intricacies of working with patients who have sustained immense relational damage and the effects on the clinicians who treat them. Courtois pays particular attention to how the dynamics of the original abuse become reenacted in the transference-countertransference relationships in the therapy.
Although this book is a truly academic work and a source book for both historical and current information in the trauma field, its primary value is for practicing clinicians. For example, there are nuanced discussions of the assessment process concerning how to interview and how to detect hidden presentations of sexual abuse. There are also detailed discussions of new newer treatment modalities including various cognitive-behavioral techniques, EMDR, expressive therapies, and more recent proposed treatments such as sensorimotor, somatosensory and energy techniques. As an added benefit, Treating the Incest Wound concludes with comprehensive appendices that provide a rich resource for both professionals and survivors of sexual abuse.
I have been an unapologetic admirer of Courtois over many years as a colleague, a collaborator in teaching workshops, and a reader of her published works. She is one of those gifted professionals who can combine the kind of meticulous academicity, clinical wisdom, warmth and compassion that is so evident in Healing the Incest Wound.

I am curious about ethical considerations when treating individuals who are HIV positive. What are my responsibilities as a clinician if I know that my client (HIV positive) is engaging in risky/unsafe sexual practices with someone? In this case, the other person’s life is endangered.

This issue always stumps me, thank you for your thoughts!

Jeff Barnett Responds:

Hi Stephanie. Great question. This is one that often is very confusing and challenging for psychotherapists. One of the major concerns involves the different but related roles of ethics, law, and clinical practice. I believe some of what is behind your question concerns the issue of “duty to warn and protect” that comes from the landmark Tarasoff decisions in 1974 and 1976 (Tarasoff v. Regents of the University of California.

In 1974 in the initial ruling the court opined that “where a psychotherapist had reason, arising out of a professional relationship with a patient, to believe, or reasonably should have believed, that the patient was intending to harm a specific victim, that a duty existed to warn that victim” (Mills, 1984).

In 1976 the court revised and updated its opinion, adding to the obligation to warn the intended victim with the need to take actions to protect the intended victim such as by contacting the police, and possibly by even using treatment to prevent the harm from occurring.

The Tarasoff rulings set legal precedent. But, over the years as states have passed laws to address these issues, the precedent has been codified into law. Yet, various states’ laws are different in their requirements. Some states have duty to warn statutes, some have duty to protect statutes, some have duty to warn and protect statutes, and some include treatment in their statutes. For example, in Maryland , the law is the duty to warn, protect, or treat. That is, if treatment can prevent harm to another person from occurring , it should be used first. Confidentiality should only be breached in these situations when treatment is ineffective or is not possible.

But, it is important to note that the Tarasoff rulings and these various state laws are speaking of a specific threat made in treatment to do harm (typically interpreted as lethal harm) to an identifiable victim or group of victims. This brings up several important points. First, it must be a threat to do harm. This implies that the harm did not already occur. The goal of these laws is to prevent future harm. Second, it must be an identified victim, otherwise who would we warn and who would the police potentially take action against? Third, the harm that is threatened should be lethal. If a client said in session that later that day they are going to punch their spouse, this would not meet the standards needed for breaching confidentiality.

But, if one’s state law allows for this the psychotherapist should always consider treatment as the first option. These laws do not require that the psychotherapist make a call to the intended victim and to the police the moment a client discloses such a threat. We are to conduct a thorough risk assessment, address these issues in the treatment plan, and work to address underlying issues, in an effort to prevent the harm from occurring, and thus, to prevent the need to breech confidentiality.

With regard to the issue of a client with HIV or AIDS disclosing engaging in unprotected sex with other individuals this is of course a very serious concern that will hopefully be addressed in treatment. With regard to breaching confidentiality there are several issues of relevance and great importance. First, it is essential that we always include potential limits to confidentiality in our informed consent agreements with our clients.  Then, the following factors are relevant: intent to do harm, likelihood of actual harm occurring, the inability to know the identity of future sexual partners, and the likely presence of consent to engage in these behaviors (Chenneville, 2000). When it comes to unprotected sexual behavior one might reasonably argue that your client’s partners are engaging in this behavior consensually. To date there has been so much education about sexually transmitted diseases, practicing safe sex, and the like, that this situation can be seen as substantively different than the typical Tarasoff-like situation. Of course, if your client stated in session that he was going to rape a specific individual in the future and to do so without a condom, that might more closely approximate the need for the Tarasoff-like actions described above. But, when considering lethal actions, unprotected sex by an HIV-Positive or AIDS-infected individual is does not possess the lethality of shooting, stabbing, etc. another person. The rate of transmission of HIV from unprotected sex is not even close to 100% and for those who are infected there now exist effective treatments.

Thus, it is important to keep in mind the requirements of your state’s laws. This includes duty to warn, protect, and treat laws as well as those relevant to reporting HIV. Some states do not all the reporting of HIV or AIDS status by licensed psychotherapists (e.g. Wisconsin) while other states require the reporting of it (e.g. Washington). So, knowledge of the relevant laws in one’s jurisdiction is essential. It is also important to keep in mind that breaching confidentiality due to harm to others has strict limitations. The harm must be threats of harm in the future, not in the past or ongoing. Additionally, the harm typically must have potentially imminent lethality (again, check your state laws for their specific wording). Finally, if these issues can effectively be addressed in treatment, that is preventing the risk of future harm through treatment, that should carefully be considered unless your state’s law contraindicates this. When addressing these issues are addressed in treatment it is important to thoroughly document all discussions, recommendations, interventions and actions taken, your client’s responses, and all consultations. Further, it’s not just important to document what you did, but also all that you considered and the rationale behind your decisions.

I hope this is helpful to you. I do not represent myself as an attorney or an expert on every jurisdiction’s laws, and I do not know all the details of your case. But, I do hope this provides some issues for consideration and discussion. Please feel free to share your comments and any additional thoughts. I also welcome other members sharing their thoughts and perspectives on this important and challenging issue.

References

Chenneville, T. (2000). HIV, confidentiality, and duty to protect: A decision-making model. Professional Psychology: Research and Practice, 31(6), 661-670.

Mills, M. (1984). The so-called duty to warn: The psychotherapeutic duty to protect third parties from patients’ violent acts. Behavioral Sciences & The Law, 2(3), 237-257.

By Staci Weiner, Psy.D.

Apple Psychological, LLP.
www.applepsychological.com.

Choose to be Happily Married, How Everyday Decisions Can Lead to Lasting Love by Bonnie Jacobson, Ph.D., Publisher Adams Media, May 2010.

This is a relationship road map; a manual for relationships that leads to successful communication, listening skills, and ultimate connection between two people. Illustrating twenty-five crucial turning points, the author raises the reader’s consciousness about critical individual and relationship decisions.  Readers learn how to translate the abstract emotions of everyday life into concrete expressions, making them more manageable in the process.

Dr. Jacobson empowers readers to make conscious choices in moments of empathic disconnect between themselves and significant others as well as encouraging readers to explore inventive ways of working with conflict and constructive forms of aggressive expression. The approaches discussed are derived from attachment theory, neurobiology, and theories of healthy aggression and conflict resolution to help people manage their daily life without being a victim of their own history.

This work helps readers gain insight into some of the choices that can lead to lasting love including:

• Learning different ways to respond or react to conflict in the moment
• Learning  to pick and choose your battles and decide when and how to establish boundaries
• Developing new ways to be tolerant of your partner’s need for personal space, change, and his/her own family values
• Developing self-awareness and control with regard to your role in the relationship and your own style of interacting
• Establishing effective communication
• Sharing your thoughts and yourself
• Using intimate listening skills
• Supporting and empowering your partner
• Understanding the difference between joy and happiness and embracing what lasts

This book is a modern dissection of relationships that acknowledges how roles shift over time.  It can be immensely helpful to couples who struggle with communication and listening skills as well as those who have difficulty establishing and maintaining personal relationships. Enjoyable and easy to read, the author uses everyday examples to illustrate her points.  The Emotional Turning Point Test at the end of the book allows readers to gain insight into themselves.

There are several online Self-Help Book Clubs in which participants read selected chapters and discuss them with other readers and mental health professionals.  More information on the Self-Help book clubs can be obtained by going to www.applepsychological.com and www.drbonniejacobson.com.

I have a client (18yr female) who I have seen twice a week for 8 months who is currently in a relationship plagued with intimate partner violence. This has been dubbed “mutual combat” by several of my co-workers, but in exploration with her, it appears as though the severity of his violence, his physical strength, and his emotional control create a dynamic where she sometimes reacts with violence (i.e., pushing him so she can escape, scratching his arms when they are around her neck). She has asked to begin couples therapy with her partner, and he has agreed. I am familiar with some of the literature on couples therapy and intimate partner violence and have had some training in this area, but no one else at my location (a community mental health center) is trained in couples therapy and/or intimate partner violence. My agency is now discussing the possibility of me seeing them as a couple while continuing to see her. Are there guidelines or best practice recommendations about
whether it would be appropriate for me to see them as a couple?

Response by Jeffrey Barnett

Thanks for this great question. I’m really glad you are asking it. Clearly you are sensitive to the issue of competence with regard to the knowledge and skills needed to provide couples therapy. As your question implies, being competent in individual psychotherapy doesn’t necessarily translate over to clinical work with couples. Once must have the necessary education and training from course work, readings, CE activities, and supervised clinical experience before expanding our practice into a new area. I agree with you that you need to be aware of relevant practice standards and guidelines as well.

The situation you describe is also challenging because of the highly volatile nature of the relationship and the risks present for all involved (including yourself!). It will be important to be sure you have in place safeguards to protect yourself should anyone become aggressive or violent during a session. Having a colleague present or nearby during sessions, having a ‘panic button’ at your desk to quickly summon security if needed, positioning yourself near the door and not having clients seated between you and the door each may be important. Additionally, having a treatment contract/informed consent agreement that clearly specifies rules of conduct for the psychotherapy relationship is important as well. It should specify acceptable and unacceptable behaviors, appropriate alternatives to use if one is angry, and responses or consequences that will occur should certain specified behaviors happen.
With regard to the competence issue and relevant standards I suggest you consult with colleagues who are experts in couples therapy and in clinical work with intimate/partner violence. APA’s Division of Family Psychology and the Family Psychology section of the American Board of Professional Psychology may be good resources. While you may not have a competent supervisor on site, consultation and supervision may be done across distances by use of televideo communications such as Skype or by telephone and by sending the supervisor tapes of sessions with appropriate consent of the clients.

You are wise to be concerned about practicing in a new area without first knowing relevant practice standards, obtaining needed education and training, and receiving ongoing consultation or supervision. Then, should you proceed with this case, be sure your expert colleagues provide suggestions on how to structure the treatment sessions and relationships to ensure the safety of all involved. I hope this is of help. Should you have additional questions or comments please let me know. I also hope others will share their thoughts on this important area of practice as well. Perhaps some colleagues who work with these types of couples can share their perspectives.

Thanks and best wishes – Jeff

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Currently, there is a push for people to be on medication, and clients often come in stating that they want medication. This is especially true in multidisciplinary environments where psychiatrists and APRNs work alongside psychotherapists. However, some people do not have this mindset. For therapists who believe that medication only needs to be used as a last resort or in obvious serious situations, is it ethical to not refer everyone to a med provider, and instead of offering medication right off the bat, to wait and try and achieve success in therapy first, in the hopes that medication will not be needed?

Response By Jeffrey Barnett

This is a great question and one that all psychologists and psychotherapists should carefully consider.  It is true that some mental health patients must have medication included as a part of their treatment. These may include those suffering from Bipolar Disorder, Schizophrenia, and other serious mental illnesses. But, even for these patients, we know that medication alone does not provide the best treatment outcomes. Even for these patients, psychotherapy and psychoeducation are important components of their treatment. Many of these patients struggle with medication compliance for a variety of reasons to include side effects of their medication. We also know that for many mental health patients, even those for whom medication may be of help, that many of them will also benefit from psychotherapy alone or a combination of psychotherapy and medication. Fairly recent data demonstrate that psychotherapy can result in many of the same changes in the brain that medication causes, and without the significant side effect potential or the potential for drug-drug interactions.

It is unfortunate that we live in a time where pharmaceutical companies directly market their products directly to consumers and the health insurance and managed care industries often take a myopic view due to fiscally motivated treatment decisions. Some patients may not be allowed to see a psychotherapist under their insurance plan until they have tried and failed with two or three medications. That’s really tragic, especially with all we know about the effectiveness of psychotherapy.

I believe your question brings up several important ethics issues. The first is informed consent. It is important to share all reasonably available information with your clients to assist them in their decision making. While we shouldn’t overwhelm them with information, it is important to ensure that they understand the reasonably available options and alternatives for their treatment along with their relative risks and benefits. This will then assist them to make more thoughtful and informed treatment decisions. The second important issue is that of competence. If we aren’t sufficiently knowledgeable about psychopharmacology and psychotherapy we can’t provide the relevant information and can’t effectively assist patients to make the most informed decisions possible.  We should also explore with patients their motivations for wanting medication. They may be seeking a quick and easy ‘fix’ for their difficulties. Again, providing them with relevant information will assist them to have realistic expectations of treatment whether psychotherapy alone, medication alone, or a combination of the two. Finally, when our psychotherapy patients are being treated with medication it is important that we address confidentiality and consultation issues with regard to coordinating treatment with their prescribing physician (or other professional). We should ensure that we have appropriate consent from our patients before sharing information with others, but should stress the importance of coordinating care with our patients. We can monitor for side effects, positive effects, and the like. The prescribing professional may only meet with the patient for 15 minutes every 6 months whereas we may meet with the patient for 50 to 60 minutes each week.  For those patients taking medication in addition to our psychotherapy we can play a valuable role in monitoring their functioning and progress.

We can also work to educate prescribing professionals about the short and long term benefits of psychotherapy for a wide range of presenting problems. In the multidisciplinary environment it can be very important to provide inservice training on psychotherapy. You could also provide consultations on patients at intake and explain treatment options then.

There is not obligation to refer all patients to a prescribing professional right away, but this goes back to the points raised about informed consent. One thing you can do is in your practice literature (as well as on your website if you have one) you can describe the services you offer along with your treatment approach and practice philosophy. That may be a good way to let patients and potential patients know how you approach treatment for a range of presenting problems. Then, if they still want to meet with you could go through the informed process as described earlier. But, you should endeavor to provide patients with accurate information, not just personal opinion. Also, it is important to ensure that all patients are medically cleared for treatment and if medical conditions exist that may impact their treatment referral for appropriate medical care is essential (e.g., diabetes, hypertension, etc.).

What you ask about is a true ethics dilemma; that is, there is no clearly correct or incorrect course of action. The best course of action depends on a number of issues and factors as described above. What makes your practices ethical or unethical is the actions you take, the actions you choose not to take, and the rationale for doing so (along with following the dictates of the ethics code and relevant state laws).

I hope this is of help. If you have additional questions or comments please post them here. Thanks for seeking this consultation. I hope others can benefit from reading it and will respond as well.

Best wishes – Jeff

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Jeffrey Barnett

Jeffrey Barnett, Psy.D., ABPP is a Professor in the Department of Psychology at Loyola Univeristy Maryland and a licensed psychologist in practice in Arnold, Maryland. He is a Diplomate in Clinical Psychology and in Clinical Child and Adolescent Psychology of the American Board of Professional Psychology and a Distinguished Practitioner of Psychology in the National Academies of Practice. He is a recent past chair of the Ethics Committee of the American Psychological Association and has previously been chair of the Maryland Psychological Association Ethics Committee. Dr. Barnett has published numerous articles, chapters, and books on ethics and professional issues in Psychology and has given numerous presentations and continuing education ethics workshops for psychologists and other mental health professionals. His most recently published books include Ethics Desk Reference for Psychologists (APA Books, 2008, with Brad Johnson), Ethics Desk Reference for Counselors ( ACA Books, 2009, with Brad Johnson), and Financial Success in Mental Health Practice (APA Books, 2008 with Steve Walfish).

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