Structured, Time-Limited, Mastery-Oriented Therapy Groups for Sexually Abused, Preadolescent Children1

Billie F. Corder*

ABSTRACT: A structured, time-limited, mastery-oriented therapy group for sexually abused children is discussed and specific techniques used in the groups are described.  The focus of the groups was in developing adequate coping skills along with mastery of the experiences connected with sexual abuse.  Feedback from parents and caretakers suggest that the children who participated in the group showed a decrease in symptoms, improved grades, and an investment in being in the group
  

Terr (1981) and Mowbray (1988) have questioned the effectiveness of some traditional short-term individual therapy interventions for reducing post traumatic stress type behaviors in traumatized children.  Particularly for sexually traumatized children, Berliner and others (Berliner & Ernst, 1984; Berliner & MacQuivey, 1984; Burgess & Holmstrom, 1987) have suggested group therapy as the treatment of choice, citing the group experience as necessary for these children to understand their "sense of differentness," and to deal with the negative self-concept which results from the abuse.  Berliner has developed a structured time-limited group format for these children aimed toward developing intellectual understanding and cognitive integration of reactions to the abuse which involves developing a cohesive relationship with peers who have also experienced abuse, development of protective behaviors to avoid future victimization, and improvement of self-esteem.

Our own work integrates these concepts with those of Rutter (1978) and Anthony (1987) who have studied the defense mechanism of "invulnerable children," defined as those who, despite trauma and chronic stress, have developed adequate coping and functioning mechanisms for daily living.  Their work has defined the typical coping mechanisms displayed by these children as ability to use intellectualization, cognitive relabeling, effective problem solving, ability to seek help and support from the environment, and capability for maintaining self esteem.

Our program attempted to help sexually traumatized children develop similar coping mechanisms with a specific focus on developing mastery of the experiences connected with sexual abuse.  Goals for the program were:

a) Improvement of self-esteem through cognitive relabeling, role play, chants and cheers, and relationships with other abused children to counteract feelings of "differentness,"

b) Cognitive and emotional mastery and integration of the abuse trauma through structured group discussion, therapeutic games, and use of art,

c) Improved problem-solving skills through structured learning experiences such as special board games and role playing,

d) Improved ability to seek support and protection from others in the environment to avoid future victimization, and

e) Improved relationships between mother and child through understanding of the abuse experience and their own behaviors and reactions.
  

Techniques

The Group Members and Materials

Many of the materials and techniques utilized with these groups were developed over a two-year period in work with individual and family groups surrounding the experience of sexual abuse (Corder & Haizlip, 1989).  Members of our pilot girls' groups were aged 6 to 9, and had been referred by a local department of social services.  Most had some brief primary intervention, and were victims of short-term abuse without severe physical violence.  Most of them were described as having an adequate adjustment prior to the abuse which had been perpetrated by family members including stepfathers, boyfriends of mothers, uncles and grandfathers.  Children's symptoms were typically described as "mild to moderate," and included mild sleep disturbances, excessive sexual concerns, and some mild withdrawal and/or symptoms of depression.  Some mothers attended sessions and were also seen individually by social work staff.

The groups met for 16 to 20 one hour weekly sessions which were focused on:

1) Introductory sessions where goals and focus for the group were established,

2) Informational sessions designed to develop intellectualization defenses as well as develop verbal skills in describing feelings and experiences,

3) Sessions focusing on cathartic release and coping with feelings associated with the abuse,

4) The development of specific mastery skills such as problem solving, building self esteem, identifying potential help from the environment, and avoiding potential victimization,

5) Sessions for closure and summarization.
  

Coloring Books on the Sexual Abuse Experience

The children used the pleasurable experience of coloring in a therapeutic coloring book developed by the author to stimulate discussion and expression of feelings.  The theme of the coloring book was, "Wouldn't it be nice," and dealt with the children's 'wishes and fantasies that the abuse had never occurred, balanced by the reality-based theme, "But the way it REEELY is ..."  Each page of the book had drawings and text related to these themes.  For example, drawings illustrated this idea "Wouldn't it be nice if ... children grew up and never had an adult or older child give them a wrong touch or made them do things that the adult or older child knew were a wrong touch.  Wouldn't it be nice if all touches were nice, right touches?"  This was illustrated in conjunction with a matched drawing which said "The way it REALLY is, is that you are not the only child who has had a bad' wrong touch.  There are many, many boys and girls in every town that this has happened to.  Some people have said that out of every four or five children, at least one has had a wrong touch, or been made to do things which are wrong touches.  When this is on their private (sexual) parts, it is called sexual abuse.
  

Developing Self-Esteem Through Cognitive Relabeling

The author and coworkers used activities similar to the "brags" listed by Berliner and Ernst (1984) in their work with older victims.  The group leaders modified these techniques for younger children and added a variety of changes and "cheers."  After each session, the group leader went around the group having members exchange positive statements about each other, following these activities with rhythmic hand clapping cheers and chants such as:

I'm a good person, I'm proud of me.
I've been through a lot, but look how strong I've got.

 

That was then but this is now.
I won't be abused and I know how.
  

Homework Assignments Participation of Mothers

In some groups mothers' participation was limited to working with group members outside of the group to complete their homework.  This consisted of sheets requiring filling in the blanks which covered information and exercises which had been completed by the group in their sessions.  In working together on this task, the children developed feelings of mastery (they had already reviewed the material in group).  The task also provided repetition of didactic material and allowed a structured format for positive interactions between mother and child as the mother was able to reinforce the material covered by the group.

In some other groups, mothers were able to attend sessions and assist their children in completing exercises and were allowed to join in on every exercise.  This level of interaction and participation was perceived by the group leaders and parents as very effective, and will remain the treatment of choice when transportation and work scheduling for mothers can permit their involvement.
  

The Moving On and Getting Stronger Game

In order to encourage a positive relabeling of children's experiences, a number of original board games were developed.  The Moving On and Getting Stronger Game is a board game illustrated with pictures showing children moving in a progression from "Sad Valley" to "Mixed-Up Mountain," toward "Learning Lake," "Positive Prairie," and "Safe Plain," and finally to "Smart Mountain," as they handle their feelings about the abuse experience and begin to feel mastery and safety.  The children rolled dice, moved their game pieces to corresponding places on the board, and responded to stacks of cards requiring them to do various tasks.  These included:

Learning Card Tasks: Reinforcement and repetition of informational and discussion material from the group, requiring the children to fill in the blanks or having the group help them answer direct questions.  An example of these cards is: "Ask the group to make a guess about how many children in our city have been sexually abused.  Tell why you think your answers are right or wrong and why.  The group leader will help you."

Practicing Card Tasks: Practice in problem solving, allowing the child to develop coping skills, increasing their self-esteem, and decreasing the potential for further victimization.  An example of these cards is: (read aloud by group leader) "A person in your church who has made you feel funny or scared in the past asks your mother to take you to the park on a picnic.  Let's practice what you would say to your mother and what you would do."

Telling Card Tasks: Encouragement of cathartic discussion of feelings surrounding the abuse within structured limits, involving a fairly low level of personal disclosure, and including some practice in mastery skill building.  An example is: "Tell how you picked out the person you finally told about the abuse.  Why did you choose him or her?"
  

"That Was Then, But This is Now" TV Game Show

With the group leader as a TV "Host," mastery activities and skills were practiced and the process of intellectualization was encouraged by the participation of the group members as "contestants."  Two teams of group members used a microphone and our TV camera to answer questions about material discussed in the group, and all team members received small prizes (candy, gum, etc.).
  

Matching Feelings and Faces Exercises

Many of the group activities used a set of "Dr. Corder's Feeling Faces," showing a small girl's face with a variety of expressions and labeled with these feelings (guilty, sad, mad, happy, mixed up, angry, scared, confused).  At times children who were unable to express their feelings verbally were initially able to use the pictures, and later to describe them verbally.  These cards were particularly helpful in the "Wanda's Story" game.
  

"Wanda's Story"

A story had been developed by the author specifically to be read aloud in the group to encourage the children's involvement in a group exploration of their similarly shared feelings and experiences.  In the story, a child named Wanda experiences sexual abuse and deals with her own feelings and the responses of others in her environment.  Throughout the story the leader pauses to allow each child to select, from their stack of feelings cards, the feeling they perceived Wanda as experiencing.  Discussion surrounding the story reading is designed to foster intellectualization defenses as Wanda progresses from experiencing victimization to feeling safe and able to protect herself with the help of others.  Eventually she is described as teaching the things she has learned to her own daughter, Wanda, Jr.

After reading Wanda's story, each member of the group follows a format titled, "My Own Story," which allows the children to fill in the blanks of a story of abuse read by the leader, describing typical experiences and allowing them to select "feelings showing on faces" from their card stack to illustrate their inner states.  The exercise is concluded with a drill on all of the children's specific plans for protecting themselves and avoiding victimization, as well as their plans for working on handling their "mad and sad" feelings.
  

Therapeutic Art Activities

Following the reading and creating of their "own story," each member was sent to a private spot in the room and instructed to draw a picture of the "worst thing about what happened to you when you were abused."  Some children were able to draw only very primitive representations of their experiences, including being sent to a foster home, testifying in court, etc., while the therapist moved about the room to speak with each of the children about their individual drawing, encouraging verbalization of feelings.  The exercise was followed by instructions to draw pictures of themselves showing them feeling and acting "smart, safe, and strong," because they had learned how to stop abuse, to get help, and to protect themselves.  Most sessions ended with the group members receiving positive strokes from each other and the leader (similar to the "brags" described by other workers), and repeating their cheers and chants.
  

First Lady Picnic

In one of the closing sessions, picnic-like refreshments were served while the group leader role played the "First Lady" attending the picnic to congratulate the children on completing the group, and allowing them to "take a message back to the President."  Typically the children took this exercise very seriously and asked, "Tell the President that he probably doesn't know how many children have been abused.  I thought I was the only one.  And tell him that every girl and boy should be able to go to a group like this one."
  

Transition Object Rehearsal and Concluding Sessions

At the concluding sessions the children were given a graduation ceremony, complete with a diploma stating they had completed the, "That Was Then, But This is Now" group about sexual abuse, listing all the tasks they had completed and topics they had learned.  In some groups a follow-up newsletter was sent to the children for a few months to remind the children of their progress in the group.  It also listed their social worker's phone number, and repeated descriptions of group members as "growing stronger and wiser" after being in the group.

Group members also received a transition object in the form of a small stuffed animal called, "The That Was Then But This is Now Wise Puppy."  The puppy was described as a way to pretend that they had a "Wise Puppy" who remembered everything they had learned in the group, and who could help them repeat it to themselves when they held him close to their ear.  The group rehearsed using the puppy to remind them when they had scared feelings that "That was then but this is now ... I know how to keep abuse from happening and what to do to stop it."  The puppy should also remind them of the people they had selected to tell about any potential abuse in the future and who could help protect them.  They were also asked to pretend that the puppy would say one good thing about themselves to them each day, just as they had given each other verbal positive strokes in the group.
  

Discussion

Children in these groups were typically described by parents and caretakers as showing marked decreases in symptoms, improved grades, and a real investment in belonging to the group.  The children themselves spontaneously made statements such as, "Before this group I thought what happened was my fault," and "I thought I was the only one this happened to."  All mothers reported that the children were more able to verbalize feelings about their experience, and were more comfortable in discussing the abuse with their mother.  One child was reported as helping a classmate report abuse to the child's school counselor.

The groups were focused on developing some the the skills described in Rutter's (1987) and Anthony's (1974) work in "invulnerable children."  It was felt that the highly structured approach helped the children to focus on tasks of building self-esteem, problem solving, and ability to seek help from others along with intellectualization and cognitive relabeling, in a context specific to their experience of sexual abuse.

Feedback from parents, teachers, and social workers indicate a generally positive result from the group experience.  The children were described as having describing increased verbal assertiveness, increased self-esteem, fewer symptoms of anxiety and presenting problems, and more positive mother-daughter relationships.  Certainly the group experience allowed opportunities for verbalization of more adequate intellectualization mechanisms for handling the abuse and cognitive relabeling was practiced in what appeared to be an effective fashion through chants, cheers and role play.

It is hoped that future groups will have time and resources available for more objective measurement of the changes which have been reported.  The author and coworkers feel that the present group format is an effective and successful method for intervention with some levels of traumatized children, and that the structure provides a mechanism for intensive focus on the mastery of the specific abuse trauma.
  

References

Anthony, E. J., & Cohler, B. J. (1987). The Invulnerable Child (Hardcover). New York. Guilford.

Berliner, L., & Ernst, E. (1984). Group work with preadolescent sexual assault victims. In I. Stuart & Greer (Eds.). Victims of Sexual Aggression (Out of Print) (pp.105-123). New York: Van Nostrand Reinhold.

Berliner, L., & MacQuivey, K. (1984). A therapy group for female adolescent victims of sexual abuse. In R. Rosenbaum (Ed.), Varieties of Short Term Therapy Groups. New York: McGraw-Hill.

Burgess, A., & Holmstrom, L. (1978). Accessory to sex: Pressure, sex and secrecy. In A. Burgess, N. Groth, L. Holmstrom, & S. Sgroi (Eds.). Sexual Assault of Children and Adolescents (Out of Print)(Out of Print) (pp. 105-124). Lexington, MA: Health.

Corder, B. F., & Haizlip, T. (1989). The role of mastery experiences in therapeutic interventions for children dealing with acute trauma: Some implications for treatment of sexual abuse. Psychiatric Forum (in press)

Mowbray, C. (1988). Post traumatic therapy for children who are victims of violence. In F. Ochberg (Ed.). Post traumatic therapy and victims of violence (pp.196-212). New York: Brunner/Mazel.

Rutter, M. (1978). Early sources of security and competence. In J. Bruner & A. Gaston (Eds.), Human Growth and Development (pp. 153-188). Oxford: Clarendon.

Terr, L. (1981). Psychic trauma in children: Observations follow-

1 Portions of this paper appeared in a pilot study report published in Child Abuse & Neglect, 1990, 14, 243-251.  [Back]

* Billie F. Corder is the Co-Director of Psychological Services, Child Psychiatry Training, Dorothea Dix Hospital and Clinical Assistant Professor, University of North Carolina School of Medicine, Raleigh, NC.  [Back]

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