Giving Kids Their Futures Back During the Holidays and All the Rest of the Year, with Michelle Miller, Ph.D., LCSW

Season 4Episode 22December 16, 2022

For children who have experienced abuse, holidays can be fraught with painful reminders of trauma, so how do we help them cope with both the highs and the lows that the season can bring?

When we think of the holidays, we often think of the sheer joy of it: Spending time with loved ones, eating favorite treats, and reflecting on bygone holidays full of those we love and traditions we love. But for many children and youth, the holidays are fraught, painful reminders of those missing from the holiday table, unexpected trauma triggers, and memories—not of sugarplums and nutcrackers, but of betrayal of trust and sexual violence.

As child abuse professionals, how do we help survivors cope with both the highs and lows that the season can bring? How do we help kids heal from trauma and find renewal and peace not only in the holiday season, but all the rest of the year, too? And most of all, how do we help kids get back to being kids? We spoke with Michelle Miller, director of mental health programs here at National Children’s Alliance, to learn how we can give kids their futures back during the holidays—and all the rest of the year.

This is our last episode this year. Join us again in January for season 5 of One in Ten.

Topics in this episode:

  • Origin story (1:21)
  • Why the holidays can be difficult for kids (2:40)
  • Watch for these red flag behaviors (5:13)
  • Be proactive to help caregivers and kids (8:45)
  • How to handle your own concerns 13:38)
  • Mental health crisis and a clinician shortage (17:04)
  • Evidence-based treatments (25:06)
  • Graduating from treatment (30:56)
  • Holiday break. See you in January! (35:36)


Michelle Miller, Ph.D., LCSW, is director of mental health programs at National Children’s Alliance

Learn more about evidence-based treatments and trauma-informed care at Children’s Advocacy Centers

U.S. Surgeon General information and resources on youth mental health

Trauma-Focused Cognitive Behavioral Therapy (TF-CBT)

Parent-Child Interaction Therapy (PCIT)

Child and Family Traumatic Stress Intervention (CTFSI)

Victims of Crime Act (VOCA)

For more information about National Children’s Alliance and the work of Children’s Advocacy Centers, visit our website at And join us on Facebook at One in Ten podcast.

Season 4, Episode 22

“Giving Kids Their Futures Back During the Holidays and All the Rest of the Year,” with Michelle Miller, Ph.D., LCSW

[Intro music starts]


Teresa Huizar:
Hi, I’m Teresa Huizar, your host of One in Ten. In today’s episode, “Giving Kids Their Futures Back During the Holidays and All the Rest of the Year, Too” I speak with Michelle Miller, director of mental health programs here at NCA [National Children’s Alliance].

Now, when we think of the holidays, we often think of the sheer joy of it: Spending time with loved ones, eating favorite treats, and reflecting on bygone holidays full of those we love and traditions we love. But for many children and youth, the holidays are fraught, painful reminders of those missing from the holiday table, unexpected trauma triggers, and memories—not of sugarplums and nutcrackers, but of betrayal of trust and sexual violence.

As child abuse professionals, how do we help survivors cope with both the highs and lows that the season can bring? How do we help kids heal from trauma and find renewal and peace not only in the holiday season, but all the rest of the year, too? And most of all, how do we help kids get back to being kids?

I know you’ll be as interested in the conversation as I was. Please take a listen.

[Intro music begins to fade out]

[1:21] Teresa Huizar:
Hi, Michelle. Welcome to One in Ten.

Michelle Miller:
Great. Good to see you, and thanks for inviting me to be on.

Teresa Huizar:
So even though I’ve known you for a long time, I don’t think I’ve ever asked you, how did you come to your work, becoming a clinician and knowing that you wanted to treat kids who had been victims of abuse and also train clinicians to do the same?

Michelle Miller:
Well, about 30 years ago, I went to work for child protection services, and I spent about five years as an investigator and would work with families to get them into mental health treatment. And then after that I started a Children’s Advocacy Center [CAC]. So, child abuse related work has been near and dear to my heart for the last 30 years.

And so for me, I wanted to further my education so that I could be a treating provider. I saw how desperately kids need to have qualified mental health providers and the value to the family. And so that caused me to pursue my master’s degree in social work, which I did. And then several years after that, I pursued a Ph.D. in psychology.

[2:21] Teresa Huizar:
And now here you are.

Michelle Miller:
And here I am.

Teresa Huizar:
Helping train other folks.

Michelle Miller:
Yes. And I’ve had extensive experience, especially when I was at my Children’s Advocacy Center, in mentoring clinicians, providing training to them, and then providing that supervision so that they could be providing quality mental health services to the families served.

[2:40] Teresa Huizar:
Well, you know, we’re here during the holiday season, and I’m sure over all of those years you’ve seen many of the same things that we’re here to talk about today, which is that while when we think of the holiday season, you know, we’re sort of drawn into all the images that are very typical of that, right? The fun and excitement of it, presents under the tree, and all the children are happy, and it’s a great Hallmark movie. Except that in real life, for children who have experienced trauma, and especially the trauma of abuse, the holidays are not always the happiest time. It can also be a time of difficulty.

Can you talk a little bit about why the holiday period may be difficult for children who’ve experienced abuse?

Michelle Miller:
So for children who’ve experienced abuse, the holidays oftentimes are family gatherings, right? So children are around people who they may not be around during other times of the year. And it can feel a little bit chaotic, right?

So you talked about all of the good things that we look forward to, but what also comes along with that is large groups. People that we haven’t seen before. And, you know, change of schedule and structure and all of those things that can impact kids.

For children who have had a traumatic experience, was that traumatic experience around the time of a holiday because that would be a reminder, right? So whenever we have those reminders, different points in time that remind us of that abusive experience, kids re-experience, right? So during those moments, they can experience those trauma symptoms again. So that can be one thing.

But the other thing is if there’s someone in their family or a close friend that they’re not comfortable with and that person’s coming into their home, or they’re going into that person’s home, that can also make kids feel confused and unsafe.

[4:26] Teresa Huizar:
You know, I think you raise a good point because so much abuse happens in a family context, and so you may have a child who hasn’t been around the person who abused them, except if they happen to see them at a family gathering. And I think families often don’t do very well with this in that children are sort of just expected to pretend like that abuser isn’t there or just stay away from them, or as though that’s not going to be any sort of upsetting or traumatic reminder to them.

And so I just think we place a lot of responsibility on kids who are coping with these difficult situations that essentially often families are putting them in around that. And then of course, you have kids who may not have even disclosed abuse by someone who’s in the family, or those people may have more access, and more unsupervised access, during the holidays.

I’m wondering, you know, when we’re talking about kids and their experience—or even re-experiencing—of trauma during the holidays, what kinds of behaviors or feelings or other things might be a red flag that children are struggling?

Michelle Miller:
That’s a great question. For caregivers, one is: Is the child acting out of character, right? Is that caregiver seeing behaviors that they don’t typically see with that child? So one is—and there can be more than one explanation. So it might be, you know, the child is overly expressing emotions, so sadness or anger, that would alert that caregiver that there’s something going on with that child.

The other thing is avoidance. You know, when there’s something that is viewed as a threat or has been a threat or is traumatic, the tendency is to avoid, right? And so when we do treatment with kids, we really work against that avoidance because that’s what helps them to get better. But on their own, in that situation, a caregiver is more likely to see maybe this child is clingy, doesn’t want to go into a room with other people, is staying closer to caregivers, or coming up with reasons, depending on the age of the child, on why they maybe can’t go to a certain event or gathering. .

[6:24] Teresa Huizar:
Right now in Children’s Advocacy Centers across the country, you have, you know, many, many children who are in treatment. And so, some of the things that you might see as a caregiver you might not have the opportunity to see as a clinician because you’re just not in the kinds of settings with kids where those things would be visible to you. So if you’re a professional working with kids at this time of year, what are the sorts of things you are looking for, um, to go, “Hmm. Seems like little Johnny is not doing as well as he was.”

Michelle Miller:
So sleep disturbance is one, right? In treatment we identify different symptoms or behaviors that we see in kids. And so if there’s a regression in that—so if you have a child who was having nightmares, those nightmares got better. All of a sudden, those nightmares are back. Or a child who we’ve worked to get them to sleep in their own bed and then all of a sudden they’re not wanting to sleep in their own bed. That would be another example.

You know, we see kids that will have temper tantrums or outbursts that would indicate that they’re not doing well. Schools are on holiday during the Christmas break, but, you know, is there an increase in somatic complaints? Right. “I have a headache.” “I have a stomachache.” So it really represents a change.

And for kids who’ve had a traumatic experience, the change may be going back to where they were before, right? So we’ve seen some symptoms reduce, and all of a sudden we see those symptoms creeping up again? Then, you know, we pause and explore what might be going on with that child. ,

[7:50] Teresa Huizar:
How common do you think this is that kids sort of experience this period of anxiety or upset—

Michelle Miller:

Teresa Huizar:
—during the holiday period that you see in treatment who are there because there has been an episode of abuse?

Michelle Miller:
So I would say that it’s pretty common. It’s going to depend on who their perpetrator is, right? So if it’s someone within the family where—because I mean, you’ve got the perpetrator themselves, but then you have the extended family, right? I just had someone say to me recently that they no longer have contact with the perpetrator, but there are other family members who are upset with them. So it can be, you know, is this perpetrator in the home? But if the perpetrator isn’t, it doesn’t mean that there isn’t a reminder, or that, you know, they’re uncomfortable being around other family members as well.

So I think that the holidays can be a great time, but I think for kids and for families—caregivers—it definitely can generate some of that stress.

[8:45] Teresa Huizar:
You know, knowing that, aside from clinical help, that some of the most important support for kids comes from their caregivers. What can clinicians and other child abuse professionals do to help support caregivers in supporting their kids through this period?

Michelle Miller:
Yes. So one is what we know is not all kids disclose, right? I mean, most often it’s a delayed disclosure or no disclosure at all. Kids will often feel like they’re letting their caregiver know, but it really is subtle hint. Oftentimes it’s not anything that a caregiver would pick up on.

And so my advice to child abuse professionals and clinicians and caregivers is really working with caregivers to just be in tune with their child’s behavior. What’s going on? Does something seem off? Especially that avoidance or not wanting to go to certain places or trying to stay near caregivers.

And then sleep disturbance is also another big one.

[9:39] Teresa Huizar:
Well, you know, I think about how chaotic it is near the holidays. You know, there’s always something going on. There’s something going on at school, there’s something, you know, neighborhood parties, whatever. And so I can see that sometimes it might be hard for a caregiver to even notice, amongst all of that, some of the more subtle things that are going on with a kid.

I mean, you know, if they’re having tantrums, they’re going to be noticed. But if they’re just sort of like, “Eh, I don’t really want to go to so-and-so’s house,” that might not really necessarily raise a red flag or prompt a caregiver to think that the child is anything more than just overtired. So it’s interesting and something for us to be paying attention to.

You know, is there anything that clinicians and child abuse professionals should be doing proactively? So sort of setting aside, you know, the kid’s already coming in, they have some kind of behavior, some kind of problem that they’re reporting. But is there something that, you know, we should be thinking about in the way that we’re talking to kids during this time to sort of prepare them for what the holidays will be like?

Michelle Miller:
Sure. So for clinicians, exploring, you know, “What are you most looking forward to with the holidays? Is there anything that you’re not looking forward to or that causes you concern?” Caregivers having conversations with kids: “If there’s anything that makes you uncomfortable, I want you to come talk to me.”

I think for kids, and it really is all ages but especially for our younger kids, that they know what the schedule is, right? So if you’re having a family gathering, you know, where is it going to be? What day is it going to be on? Who’s going to be there? Because I think that leads to some predictability on the child’s part.

And then also for the caregiver, to be able to have the conversation with the child on what to do if there’s a concern. I think that supervision—right—supervision can be really hard when there are large gatherings. Also, substance abuse or substance use can come into this, too, which is another factor.

But I think, you know, good supervision—families talking about where can you play, who can you play with, you know, should doors be open or should doors be closed? And making sure that adults are checking in on kids throughout the festivities.

[11:43] Teresa Huizar:
You know, thinking about the Children’s Advocacy Center setting and the fact that often we have caregivers in front of us who really want some direction from us about how to support their children in the immediate aftermath.

And unfortunately, the numbers don’t tend to slow down a lot during December, typically. You know, we’re going to be seeing kids right through the holidays, essentially. And I’m just wondering, is there something that you can think of that, for victim advocates who are talking to caregivers at the time of an interview or—or even talking with the kids themselves—that we should be thoughtful about, given the time of year that it is?

So, you know, many of these are not going to be in counseling yet. There’s not going to be a clinician who’s monitoring changes in behavior and other sorts of things. So, you know, if someone is going through this process right now at this sort of critical period, what should we be doing and talking about with caregivers and kids?

Michelle Miller:
During this time, I think it’s very good to ask caregivers, “Well, what are your plans for the holidays? Do you have any concerns about those plans? How can you get support?”

The other thing is financial stress is really a big stressor for caregivers, right? So I mean, when we look at families during the holiday time, especially if they’ve had a recent CAC visit, so there’s stress related to some allegations of abuse, we don’t know if family is divided, right? So that would be the, you know, “Who are you going to be with? Are you going to feel supported? Do you have any concerns?”

I think planning is really key, and I think it’s great if victim advocates or staff from CACs check in with families.

And then also just knowing that, you know, there’s an increase in domestic violence during the holidays. Um, and that’s because of, you know, substance use. You know, families are divided based on religion. There’s a huge political divide. So there are other factors that can also be physically and psychologically unsafe for children during the holiday. ,

[13:38] Teresa Huizar:
You know, I’m just sitting here listening as you’re talking. I’m thinking how adults wreck the holidays for kids in a thousand and one ways. Right. And we just, there are just—

Michelle Miller:

Teresa Huizar:
—so much for children to have to contend with, as you say, in all of this time.

I’m also thinking about the fact that this can be a tough time for professionals. You know, you spend all year working with kids and families and hearing allegations of abuse. And that is always hard. You know, we’re aware of vicarious trauma and those types of things. But I do think that there is an added burden during the holidays because I think you see your colleagues who do other things for a living, and they seem to be often fairly carefree this time of year. And so I think there is this extra … I don’t know, sadness that comes with a time that should be so happy. Feeling the sort of emotional weight of all of the stories of abuse that, you know, you’ve been burdened with all year and now, especially.

What should child abuse professionals and clinicians be thinking about in terms of self-care and how to, frankly, get themselves through the holidays in a way in which they can actually enjoy it with their friends and family?

Michelle Miller:
That’s such a good question. People who are in this field, we look at situations differently, right? Whether it’s the family that we see in the grocery store or the people around in our community that we know are struggling and are less fortunate. And so that can really be a heaviness or, you know, you’re working with kids and families and you know, what they’re going to be dealing with on the holidays.

So as best as possible, being able to—you know, I talk a lot about a parking lot, and we can’t completely do that emotionally, but really being able to be very present when we’re with the kids and families we serve. But then really during times, whether it’s vacation or our own holidays, being able to just try to, from a mental perspective, park it. Right? Like, I’m going to set this over here, and I’m going to pick it back up. And I know it’s there, but it allows us to have some relief, some separation, which really allows us to continue to do the work that we do every single day. We need to have our own psychological breaks from it. And so that’s one strategy that I use for myself.

You know, I’m pretty involved with kids and families up until the holidays and I know, you know, if they’re going to be having struggles or they’re sad, um, but for that period of time, being able to park it.

[15:57] Teresa Huizar:
It’s such a good way to think about it, because I think one reason people struggle with disconnecting is they feel like they’re somehow abandoning, you know, the families that they work with and that are on their mind. But in a lot of ways, you know, it’s not like you abandon your corner parking lot and never go back to it. You know, you’re just putting it there until you can come back to it, and I think that’s a really helpful way to think about that.

Are there other things that you recommend?

Michelle Miller:
So for clinicians and child abuse professionals, that you have your own traditions, you know, your own family, being able to just celebrate like you celebrate. I think giving grace—we all need to give grace to ourselves, right? Having reasonable expectations, sometimes, you know, if our expectations are too high.

The other thing for clinicians, oftentimes they want to take some time off around the holidays. And so that can be a challenge for a clinician, because maybe I’m not going to see this kid for two or three weeks because I’m taking my own time off.

So I think, you know, just having a plan—is there an emergency contact? Maybe that’s you, and maybe you have a colleague that’s going to be your emergency contact while you enjoy your time off or your time with family.

[17:04] Teresa Huizar:
I want to sort of pivot for a moment. You know, we’ve been talking about the holidays and what all is going on with that. And those are sort of particularly intense times. But you know, the Surgeon General recently released two reports that indicate that this is a tough time for America’s kids, just generally—there’s really a mental health crisis in the country.

Can you talk a little bit about that? Not necessarily specific to the report, but just—

Michelle Miller:

Teresa Huizar:
—but just overall. You know, you have your own clinical practice, you’re training clinicians every day. What are you seeing in terms of, you know, kids well-being?

Michelle Miller:
Sure. So, we’re still experiencing the results of the pandemic, right? I don’t even say “aftermath” because I feel like we’re still in the pandemic. And so, for kids and families, the last two and a half years have really changed. And so what we’re seeing is definitely an increase in depression and increase in anxiety, an increase in suicidal thinking, and even suicidal plans, right, that require emergency intervention.

And what I’ve heard from other colleagues and, some of them are working at CACs, is the acuity of cases is higher. So that means when a child comes in, they’re actually experiencing more symptoms than what we would typically see. And so there’s a greater demand for services for them, and to get services quickly.

Part of what we’re dealing with in this country is a professional shortage. We know that the workforce issues have been an issue throughout the pandemic, but there are not enough therapists for all of the people in the country who need it. Because not only are kids experiencing more anxiety and depression symptoms, but we also have adults who need services as well.

[18:39] Teresa Huizar:
This just feels like something to me that has been brewing for some time. Not just the mental health crisis around the pandemic, but this workforce shortage didn’t just arise overnight. Can you talk a little bit about what you think is driving that? Because you know, now of course, everybody’s clamoring to hire clinicians and talking about the need to train more clinicians.

But it seems like there must be some reason that more individuals are not winding up in this as a career field, given the fact that this great demand exists. So what are the drivers here, Michelle?

Michelle Miller:
One is the educational requirement, right? In order to be a clinician, you need to at least have a master’s degree. Education is expensive and it’s a big-time commitment. Also, people look at what they’re going to make after they make this investment in their education. And unfortunately for mental health providers, when you look at other career opportunities that require the same education often those pay more. So I really think that the student debt is an issue.

And then, you know, it’s hard work. You have to be passionate about it, and interested. So it’s not for everyone. But definitely I think there’s more need to get out and recruit.

I know on the federal level meetings that I’ve been having, they’re looking at trying to increase pay for providers. And so I think that that is really important.

And then also, you know, some student loan repayment programs that can help clinicians as well, so they don’t come out with a large amount of debt.

[20:04] Teresa Huizar:
Yeah, I think your point is well taken that this is a problem that is not only going to be solved by the contribution of the child abuse community but it really is a national crisis in terms of needing more mental health care providers and it’s going to take some public policy solutions as well.

I’m just wondering that, you know, in the meantime, because there’s not going to be instantaneously tens of thousands of new clinicians out there, you know, when you’re advising Children’s Advocacy Centers and, you know, child abuse serving organizations—victim serving, I should say—organizations about their mental health programs, what can be helpful given the fact that there is a provider shortage?

Michelle Miller:
Sure. So number one is screening. All kids are not going to need referral for mental health assessment and mental health treatment. There are some CACs that refer all children. That’s not effective. One, not all children are going to show up. What we know is that, you know, it’s less than 50% who will attend that first appointment.

So screening by a non-clinician—so that can be your victim advocate or some other employee of the CAC—can do that screening. And screening will inform the need for a mental health assessment, which really is the second step.

Sometimes people think about, “I’m just referring kids in for treatment, “but it’s really a stepped approach. So it starts with screening and then a quality evidence-based assessment to determine whether or not therapy’s indicated, and if it is, what kind of therapy. And then using the results to get kids into treatment.

The other thing is, NCA recognizes evidence-based treatments that have been researched to be effective for trauma, and they’re short term. And what we know—and I saw this in my own clinic when I was managing clinical services for a large health care setting—is that oftentimes kids get a lot of sessions, right? We don’t want kids to be in therapy for years or to feel like they have to be in therapy for years. Really picking an evidence-based treatment, sticking with that evidence-based treatment so that there’s fidelity. And what I would say is that if a child is receiving more than 20 to 25 sessions, it really needs to be looked at because that should be the exception and isn’t very likely.

[22:16] Teresa Huizar:
You know, it’s so interesting that you say that, because I think maybe there’s—it probably has historical roots, you know, in old psychodynamic methodologies and something, this idea that you have to go to therapy for a long, long time to get a benefit out of it. And so I think people are just—you know, I’m curious about why you think some clinicians who’ve been trained in an evidence-based treatment might still exceed the number of sessions even when the child’s symptoms have declined below a clinical level. So we’re not talking about those kids who still have significant symptoms and obviously need additional treatment, but where that’s not even the issue. What do you think that’s about?

Michelle Miller:
So one is practicing with fidelity. If they go, you know, beyond that 25, there probably is a fidelity issue there.

The other thing is that sometimes for clinicians it’s: We’re worried, we’re concerned about the kids that we serve. And so there can be this concern that maybe I’m discharging prematurely.

The other thing that can happen is caregivers. Right? I have conversations with caregivers upfront about how many sessions they can expect, because what happens is, once you start talking discharge, caregivers can also have some anxiety around that and they can bring up additional issues.

So I think for clinicians, the most important thing is not blending models. If we start to blend models, if I do a little TF-CBT [Trauma-Focused Cognitive Behavioral Therapy] and a little PCIT [Parent-Child Interaction Therapy], I have just extended the number of sessions that that kid needs.

And then just, you know, as I would say as a therapist, I’ve lost sessions where I went into a session and I wasn’t prepared. And it wasn’t harmful for the kid. Right? It was totally fine for the kid and the caregiver. But it extended the number of sessions that I had with that child. So for clinicians really being prepared, not getting stuck on—we call them the crisis of the week, where caregivers come in with concerns, we can really get consumed with the behavior problems and the crises of the week. And then it can kind of slow down the work that we’re doing in treatment.

[24:13] Teresa Huizar:
That’s interesting, because I can see how that would happen. Like if there’s a crisis at school or kids acting out at home all of a sudden, you know, then all of a sudden the caregiver wants you to focus on whatever that behavioral issue is instead of whatever you would—you know, ordinarily would be the next session, according to an evidence-based treatment. That’s really interesting.

Michelle Miller:
Can I add one more thing to that?

Teresa Huizar:
Yeah, please.

Michelle Miller:
The way scheduling is done also has an impact. So when therapists have really full caseloads, they may only be able to see that child once every two, three, or four weeks. And that also slows down the progress of therapy, right?

So when we’re figuring out what our caseload is, how many kids we can see, really what you want to aim for is trying to see weekly, so that you can get them in and get them discharged. But definitely not extending beyond two weeks, because then we’re just doing maintenance and we may be trying to do maintenance with kids who are still actively symptomatic.

[25:06] Teresa Huizar:
You know, you’re raising a really good point because I think that, if you look at community mental health, for example. Often they have just a routine practice of scheduling appointments once a month, right? And so that’s not going to be terribly helpful with any of the evidence-based treatments for kids. They’re not designed to be delivered in that way. And if they’re delivered in that way, as you say, they’re not going to be terribly effective.

So I think that’s a valuable point that CACs and other organizations may also need to look at their scheduling practices. Because if they’ve been in the habit of scheduling in a certain way and then they bring on an evidence-based treatment and learn it and are trying to practice it in Fidel with fidelity, it’s not just about what the clinician is doing in the room, it’s also the policies and procedures that drive doing that properly. So that’s a really good point.

You know, I know it’s also true that some evidence-based treatments are longer than others. Would you just talk a little bit—you know, we never want to recommend any evidence-based treatment on the basis of, “Well it’s short.” You know, these are all good for certain things and for certain reasons. But it’s also true that as a positive knock-on effect, some of them are very effective in a relatively brief period of time. And that can be really useful at a time when there are not enough providers.

Michelle Miller:
So, yes. So Trauma-Focused Cognitive Behavioral Therapy is one of the short-term therapies. It’s the most commonly used by CACs. It generally is the one that I would recommend they start with because it has a broader reach in terms of trauma types and ages. And that can be delivered in 12 to 16 sessions for kids who have complex trauma. So, traumas that are complicating their clinical picture. I would say that other end would be 25 sessions. But there’s also been research that has shown that it can be effective in as few as eight sessions.

So I think definitely when we’re looking at how do we serve as many kids as we can, we need to look at which evidence-based treatment, one is effective for the population, but also takes into consideration the number of sessions.

Another one is Child and Family Traumatic Stress Intervention [CFTSI], and this is through Yale University. And this is an acute model. So this is a therapy that’s delivered within four to six weeks after either a potentially traumatic event or when they come in for forensic interview view for disclosure, it opens up that window.

Again, this has been proven through research to be very effective at interrupting the development of PTSD for children and also caregivers who have post-traumatic stress symptoms. They have a clinically significant reduction in those as well. And it’s five to eight sessions, so very effective.

I mean, the goal of therapy is to identify symptoms and to reduce those symptoms. And what the research has shown us consistently over time is, CFTSI and TF-CBT are both very effective at doing that. In—for TF-CBT, if you can schedule monthly, it’s about four months and the child can be discharged.

[28:05] Teresa Huizar:
Which, you know, is remarkable if you think about it. I remember a few years ago talking with a VOCA [Victims of Crime Act] administrator in one of the Carolinas, and it was really interesting because prior to learning about evidence-based treatments, they had really had sort of the idea that there should be unlimited treatment available to child sexual abuse victims.

And I mean, they’ve, they were meaning to be supportive. Do you know what I mean? They were going to prioritize it for VOCA funds, the reimbursement. They were not going to cut kids off after X number of sessions. Those kinds of things. And not that you want people cut off after X number of sessions—I’m not saying that. But it was very interesting, because they were talking about the way in which funds had been able to be stretched further with the implementation of evidence-based treatment because kids were getting better in 16 sessions or 20 sessions or whatever the number was, but it wasn’t going on and on for two years, three years, you know. Just extraordinary periods of time, which is, from a public policy perspective, extremely expensive.

And also, when you run out of dollars, then what? Then you have a whole bunch of kids who don’t get served. So I think it’s just something for us to be thinking about, not only from the position of, you know, what we’re familiar with or those kinds of things, but these have a real-life implication for the number of kids that we can serve.

Which, you know, I want to segue into that for a moment, because as much as CACs are serving every possible kid that they can and are doing, I think, a really heroic job in the absence of resources to do that, it’s also true that we know there’s a gap. Can you talk a little bit about the gap between—even in the CAC world during this time of mental health crisis across the country—the numbers of kids that we think could benefit from services that are just not getting them?

Michelle Miller:
So based on our data, we estimate that about 80,000 children a year do not have access to mental health services. The other thing that we’ve heard from the field is, we train victim advocates on engaging kids and families and mental health care, and victim advocates will frequently be really excited to be learning these skills. And then they get frustrated because they can’t get kids into therapy. So there are wait lists, and they’re long wait lists. And when we look at the development of post-traumatic stress disorder, the longer a child sits on a wait list, right, it’s more likely that they will meet criteria for post-traumatic stress disorder.

[30:27] Teresa Huizar:
You know, and when you think about that, it just honestly makes you anxious about wait lists—

Michelle Miller:
Right, yeah.

Teresa Huizar:
—you know, speaking about bringing on anxiety just thinking about that. Because it’s true.

Michelle Miller:

Teresa Huizar:
You know, and you’re just thinking, it’s not just like waiting, like, “Gee, your number will get called. In the meantime, kids are suffering. And so I think we have to really continue to think and be creative as a field about how we’re going to get these 80,000 kids who we think could benefit from therapy get some service.

So, Michelle, what questions have I not asked you that I should have? Because I’m not a clinician, so I’m not going to remember or know all the things I should ask you.

Michelle Miller:
So, one point that I would like to make, and when I supervise clinicians, I talk about this. We don’t want to foster dependence from our families, right? And so I start talking about discharge during that first appointment. Just preparing them that this is what we’re going to work on, this is our time together.

And I will usually say, on the lower end, “I expect that we’ll be together for about 12 sessions. And you can always extend it if you need to.” But when kids and families come every week or every other week for a year or two, inadvertently, as professionals, we’ve fostered a dependence, right? Because they don’t feel like they can do it themselves. They feel like they need to have us, and that’s where that panic is.

And so it really is okay when kids have symptom reduction, you’ve made it through the treatment, to even take a break. I oftentimes will say to kids—and families—“If, if you need a session, we call it a tune-up, you can give me a call. We don’t need to hang together and have these sessions on a regular basis.”

There are other ways that we can support families and give them the opportunity to go out and try the skills that we’ve taught them.

[32:10] Teresa Huizar:
You know what, that reminds me of? A CAC, and I can’t remember which one now, but they were talking about when kids completed therapy, they considered it graduating.

Michelle Miller:

Teresa Huizar:
And they kind of had a little, you know, thing for them because they wanted to see that endpoint not as, “Oh, I’m so sad that I’m going to miss Miss Michelle,” you know? But as, “Wow, you know, I succeeded. My symptoms are better.”

And I just thought that was really awesome. In one place the team would line up in a hallway and the kid would walk down and they would celebrate that. I don’t know if you’ve seen other examples or what you think about that.

Michelle Miller:

Teresa Huizar:
But I was just like, I was just like, that is such a good way, I think to frame what’s actually happening, you know?

Michelle Miller:
Yes, yes. So definitely have seen that. Encourage clinicians. It’s as good for the team as it is for the child and the family to see the kids improved and that they were able to discharge and to participate in that celebration.

Also, giving them a little bag that maybe has some of their coping skills, right? So we can give them some things to take with them that remind them of their coping skills and how to use those coping skills. And that is good as well.

[33:19]Teresa Huizar:
You know, when you were talking about the team and how good it is for them, I was just thinking overall how knowing and understanding more about how kids get better, and moving kind of beyond just the investigative aspects—I mean, right there, that is so good for teams because I feel like it helps them not fall into that sense of helplessness about, you know, there’s an endless supply of abused children. Which I think whether you’re at the holiday time or any other time, that can feel very overwhelming.

And so, you know, I don’t have any research evidence I can point to, but it just feels to me like when team members have been exposed to kids getting better, they can feel better about the work that they’re doing and know that it’s meaningful.

I mean, what do you find with that when you’re interacting with teams?

Michelle Miller:
I think it’s really important for teams, right, to celebrate the successes. And what I say is, we all fight for justice for kids. And the criminal justice system sometimes cooperates with us and sometimes doesn’t. But we can all participate in kids healing. That’s something that we can do. And that really is taking that child and giving them their future back.

And so this is hard work for teams, and when they only see the negative, that is really wearing. So I think being able to balance that with the success stories is extremely important. And having them participate in that.

[34:39] Teresa Huizar:
Giving kids their future back. I mean that’s such a beautiful way to think about it.

Well, I’m going to let you have the last word, Michelle. Is there anything else that you’d like to remind our listeners to be thinking about and talking to kids and families about during the holiday season—or any other time?

Michelle Miller:
Just, I want to thank all of the CAC staff, child abuse professionals, law enforcement, all of the multidisciplinary team members for the services that you provide to kids. It really makes a big difference for those kids and caregivers. And you know, we can keep doing this, and I think that, you know, over the last decade, we’ve really looked at mental health—and children deserve the right to heal. They really do. I view that as a right. And at CACs, we know what evidence-based treatments work, so let’s work together so that we can make sure that those 80,000 kids receive the services that they need.

[Outro music fades in]

Teresa Huizar:
Thank you so much, Michelle, for coming in and sharing your education and wisdom and expertise with the group. We really appreciate it.

Michelle Miller:
Thank you.


[35:36] Teresa Huizar:
Thanks for listening to One in Ten. We’re taking a little holiday break, and we’ll be back in January with another great season of guests. We wish you a restful and peaceful holiday season, and we’re so grateful for all your support.

For more information about this episode or any of our others, please visit our podcast website at