Effective Treatment for Children in Cases of Extrafamilial Sexual Abuse

Therese L. Wolf and Terence W. Campbell^*

ABSTRACT: Many therapists believe that individual therapy is the most appropriate therapeutic treatment fir children who have been sexually abused.  They assume that working with the child on a one-on-one basis will reduce the effects of "trauma."  However, this belief is not empirically supported.  This paper outlines a family therapy technique for working with the non-incestuous family whose child has been sexually abused Through this approach, parents develop the confidence and ability to assist the child and become the child's major support system.
  

We maintain that it is inappropriate to treat children for sexual abuse per se.  Sexual abuse is an event, not a clinical condition.  Undertaking treatment for children only because they have been sexually abused, without specifying the condition that warrants treatment, is tantamount to physicians claiming that they treat patients for automobile accidents.  In fact, many people involved in auto accidents never require medical treatment; and when they do, treatment responds to their clinical condition (e.g., fractures, concussions, internal injuries, etc.), rather than the event responsible for the clinical condition.

Similarly, Beutler and Hill (1992) observe that, for adult clients contending with a history of childhood sexual abuse, treatment is most effective when it responds directly to the clinical condition of the client.  That is, the research indicates effective treatment addresses the anxiety, depressive, dissociative or other problems/conditions manifested by the client.  Beutler and Hill also challenge the assumption that the population of adults sexually abused as children is clinically unique and requires special expertise.  We maintain that Beutler and Hill's position applies equally to children who have been sexually abused.

Appropriate treatment for sexually abused children also raises questions of whether treatment is actually necessary in a given case.  Research indicates that as many as half of sexually abused children are asymptomatic despite their abuse (Caffaro-Rouget, Lang, & van Santen, 1989).  When the abuse involves a previously unknown perpetrator, a low frequency of sexual contact, no use of force, and no experience of penetration, the child is less likely to develop symptoms (Kendall-Tackett, Williams, & Finkelhor, 1993).  In these circumstances, treatment can be short-term and problem-focused, assisting parents to provide the psychological and social support their child needs.  Excessive treatment in such cases creates the risk of iatrogenic outcomes.  Treatment above and beyond what is necessary suggests to children and their parents that the child's condition is especially serious; and in turn, the child's psychological welfare can suffer as a result of self-fulfilling prophecies.

Even when the child does exhibit a clinical condition warranting treatment, the research contraindicates individual psychotherapy for such children.  Sexually abused children recover more completely as the levels of enmeshment and expressed anger in their families decrease (Kendall-Tackett et al., 1993).

Reducing parental frustration and self-doubt is a crucial goal when treating sexually abused children.  Parents understandably struggle with considerable frustration and self-doubt as they attempt to aid their child.  Since frustrated, self-doubting parents suggest to their children that their situation is a serious one, they can inadvertently prolong their child's recovery.  Children cannot recover age-appropriate, normal behavior until they know their parents feel comfortable and self-confident about their situation — but the parents cannot feel comfortable and self-confident until they see their child behaving normally.  Therefore, treatment typically involves a challenging impasse: The child cannot be "OK" until the parents are "OK," but the parents cannot be "OK" until the child is "OK" (Campbell, 1994a).

In addition to considerations of this impasse, the research related to treatment effectiveness for children in general advises against individual therapy for children who have been sexually abused.  Removed from the carefully defined and closely supervised treatment protocols of academic-research settings, the accumulated evidence clearly demonstrates that individual psychotherapy for children is no more effective than no treatment (Weisz, Weiss, & Donenberg, 1992).  Also, Gorin (1993), in assessing the effects of individual therapy for children in a community mental health center, reports that parental behavior change is one of the variables most predictive of treatment effectiveness.  Therefore, in view of the demonstrated significance of parental response to child therapy, neglecting to systematically include parents in treatment for their children is ill-advised.

Data underscoring the inadvisability of individual therapy for children are especially applicable to play therapy and other expressive modalities (Campbell, 1992a,1992b).  As long ago as 1975, Davids observed that the time had come to abandon the prevailing blind faith endorsing the activities of play therapy rooms.  Play therapy for sexually abused children creates the risk of prolonging their recovery via mood congruent memory effects (Matt, Vazquez, & Campbell, 1992; Singer & Salovey, 1988).  Play therapy characteristically encourages dramatic expressions of affect that are presumably cathartic for the child.  But these supposedly cathartic expressions can be continual reminders of the distress and trauma of the abuse, and consequently, the child's recovery may be prolonged.

Effective treatment for sexually abused children requires well-defined treatment goals specifying both ultimate and instrumental outcomes related to therapy (Rosen & Proctor, 1981).  Ultimate outcomes in treatment correspond to the outcomes the therapist intends to realize by the time therapy terminates.  Instrumental outcomes refer to the well-defined interventions therapists undertake to realize ultimate outcomes.  The direct participation of parents in therapy for sexually abused children facilitates the realization of both instrumental and ultimate outcomes through social support.

Social support refers to the encouragement, assistance, and reassurance available to individuals from their network of recurring relationships with other people (Campbell, 1994b).  High levels of social support protect people from the adverse effects of stressful life events and chronic life strains (Cohen & Hoberman, 1983).  There is overwhelming evidence underscoring the significance of social support in maintaining effective psychological adjustment (Cohen & Syme, 1985; Cohen & Wills, 1985; Sarason, Sarason, & Pierce, 1990).

Social support, however, is not a unitary phenomenon.  In his review of the relevant literature, Evans (1993) identified four different types of social support: (a) esteem support, actions or statements that provide people with evidence of their own worth; (b) informational support, advice or guidance that is helpful in coping with problems; (c) instrumental support, which consists of sharing, helping, and other forms of prosocial behavior, and (d) companionship support, which provides a sense of belonging through shared activities.
  

Investigation vs. Therapy

Since appropriate treatment in cases of extra-familial child sexual abuse responds to the clinical condition of the child, treatments that speculatively address why the condition has developed fail to resolve problems.  Instead, effective treatment addresses what courses of action can be undertaken to ameliorate the child's clinical condition (Campbell, 1993).  The therapist works with the child's family to help them manage problems resulting from the sexual abuse.  Effective treatment precludes therapists from undertaking investigative responsibilities (Hoorwitz, 1992).  An investigation attempts to determine exactly what events transpired in the past related to the child's abuse.  In contrast, appropriate treatment addresses how to increase the effectiveness with which parents respond to their child's clinical condition.

In view of the very different kinds of tasks facing investigators and therapists, investigators should complete their work before therapists undertake treatment (Ceci, Ross, & Toglia,1989).  Once treatment has begun, therapists are obligated to inform investigators that treatment is designed to serve the welfare of the child, not the purposes of the investigation.  Though investigators can assist the treatment process — by informing the therapist of the legal status of a case — there is very little that therapists can do to aid the investigation.

Investigators can offer valuable information on the court process that may affect the parents and child.  The therapist can then assist the family with frustrations resulting from the delays, adjournments, and postponements that often hinder the legal system.  Parents can be educated as to the normality of this process.  They are allowed to express their frustrations so that their children do not see them as angry, anxious, worried, or upset.  Alternatives for coping with the long waiting periods in the legal process can be discussed.  Suggestions may include the child being on call instead of waiting, encouraging the parents to be in touch with their contact person (police, prosecutor, victim witness advocate, etc.) to determine the status of the situation, and bringing items to keep the child and family busy during these times.

Also, the therapist should obtain the results of any medical examinations or tests that have been performed.  Having this information enables the therapist to anticipate and deal with any medical procedures, illnesses, or injuries the family might be dealing with.  Or, if no further medical attention is needed, the therapist could work with the family's relief that their child has no physical illness or injuries.
  

Treatment for Clinical Conditions

A child who has been sexually abused may exhibit many different types of clinical conditions (Kendall-Tackett et al., 1993).  These can include masturbation, nightmares, problems concentrating, nervousness, somatic complaints, acting out the event, refusing to speak about the incident, crying, not wanting to be left alone with certain people or people of a certain sex, clinging, having trouble falling asleep, etc. (This listing is not meant to be complete or exclusive by any means.)  These conditions can be grouped under various categories and identified as sexualized behavior, depression and withdrawal, anxiety, and dissociation.  It must be emphasized, however, that these symptoms, in and of themselves, do not mean that the child has been sexually abused since such symptoms can have many different causes.
  

Family Involvement

Effective treatment for sexually abused children necessitates the active participation of the child's family.  The therapist assists the family in developing a treatment plan and setting appropriate goals to solve the presenting problems (Haley, 1983).  The approach emphasizes developing well-defined strategies for working on specific problems.  "Interventions usually take the form of directives about something that the family members are to do, both inside and outside of the interview.  These directives are designed to change the ways in which people relate to each other and to the therapist" (Madanes, 1981, p. 23).

The therapist and parents comprise the collaborative partnership to develop the treatment plan for changing behavior and assisting the child and to establish treatment goals (ultimate outcomes).  The parents offer their thoughts, ideas, and concerns as to what they believe will help their child.  The therapist asks what has already been tried since obviously, these efforts have not worked or else the family would not be in therapy (Fisch, Weakland, & Segal, 1988).  The therapist then makes observations and gives suggestions based on the parents concerns in an effort to reframe the situation and move the family forward (Minuchin & Fishman, 1981).

Once the parents and therapist agree, the therapist outlines the goals of treatment (ultimate outcome) and then works with the parents to develop treatment strategies (instrumental outcomes).  The treatment strategies are the step-by-step, day-to-day activities that will help the child and parents address the problems that brought the family to therapy.  This process helps the parents feel more in control, increases their confidence, and reduces their self-doubt.  The parents must be an integral part of therapy since they provide essential social support to the child.  The therapist is merely available to assist the family.

Throughout, therapists bring their expertise, education, training, and life experiences to the family.  They remind the parents of the normality of some of the child's activity/behavior based on the child's developmental stage.  They encourage and support the family as the parents and children complete the assignments and change their behaviors.
  

Treatment for Overtly Sexualized Behavior (performed by the child alone)

The most distinctive problem behavior characterizing some sexually abused children is overtly sexualized behavior.  This can vary in its focus.  The child might masturbate or perhaps rub the genital area on a person or on soft objects such as stuffed animals, towels, or bedding.  Or the child might engage in sex play with another child.  This should not be seen as further abuse, but rather as relieving the charged-up sexual tension the child may have experienced as a result of the sexual abuse.

Madanes (1984) describes a technique of a nonparadoxical ordeal which can be used with an overtly sexualized child.  The goal of this technique is to make the sexualized behavior less attractive.  It also removes the parents from the role of continually chastising the child about the behavior.  The technique is designed to set parameters for the behavior and ultimately eliminate it.

The specific ordeal example presented here is based on suggestions Jay Haley outlines in his book, Ordeal Therapy (1984).  The parents bring their young daughter to therapy and report she has been rubbing her genital area constantly on different objects.  They want the behavior to stop.  The therapist explains to the parents and child that, if the child is going to perform the activity, she must perform it accurately and appropriately.  Therefore, the therapist works with the parents and instructs how to establish a specific set of steps before the child is allowed to begin the behavior.

First, the parents and child select a proper room and the proper stuffed animal.  They review the merits of each room in the house and debate the pros and cons until an appropriate room is chosen.  Next, they evaluate the benefits and liabilities of every stuffed animal.  The parents narrow down the choices, but the child makes the final decision.

After the selection of the stuffed animal and room, the child chooses where in the room the behavior is to take place.  For example, if the behavior is to occur in a bedroom, the child must decide whether it will occur on the bed or elsewhere.  If on the bed, another decision is made whether to have the bed covers up or down.  If the covers are to be down, the parents practice the precise removal procedure with the child.

Next, the parent and child determine which clothes the child is to wear and which are to be taken off.  If clothing items are to be removed, the parents and child practice (with other clothing items or pretend clothes) the procedure to smooth, fold, and place them in a certain spot.

Following this, the child chooses the exact position in which she will sit or lay.  Next, with her parents' help, she determines the correct rubbing procedure.  It is practiced for the full effect and correctness of procedure.

The time frame of when to begin each activity and when to end is also carefully specified.  At home, the child must then engage in the behavior only at the regularly scheduled times.  Therefore, if the child is found rubbing herself at any time, the parents must encourage her to wait until the agreed-upon time.

This marks the end of the organization and establishment of the ordeal.  The parents are encouraged to be consistent in its implementation by reminding the child of the appointed time, setting a timer so the exact time is adhered to, and reminding the child of the step-by-step procedure.

Once this ordeal routine is established, put in place, and consistently adhered to and encouraged, it takes away the pleasure of the activity because of all of the details involved.  Additionally, if the child is engaged in the behavior as an oppositional mechanism, this, too, is removed, as the parents are encouraging the behavior.  Soon, any behavior which is organized in this way is quickly extinguished (Haley, 1984).
  

Treatment for Overtly Sexualized Behavior (performed with another child)

Another example is of a child engaging in sexualized behavior with another child.  Obviously, no parents want their child to become sexually involved in this manner.  Therefore, in therapy, the child is asked to pretend to have the symptom and the parents are instructed to assist the child with developing an alternate behavior (Madanes, 1981).

The therapist and parents explain the inappropriateness of this behavior for the child at this time.  (This must be done carefully so as not to discourage or dissuade the child from having a normal sexual life as the child matures.)  Limits and boundaries must also be explained.

The parents explain this behavior in terms of the child having extra energy which can be directed elsewhere.  The child, therefore, is asked to divert this energy to other activities which would be helpful to the parents, child, or family.  For example, there are many activities that can be done with a parent.  These can be household tasks or activities to improve a sport or academic skill or to develop a hobby.  This serves two purposes — it distracts the child and because it is done with the parent, it keeps the child from being alone with other children.  Additionally, it contributes to social support.  Therefore, the child gains from every perspective.
  

Treatment for withdrawal

Sexually abused children sometimes become withdrawn, which can be seen by their lack of interest in many areas/friends/activities that were formerly enjoyed.  When this happens, parents become concerned and worried.  They have much self-doubt.  They want to assist their child in any way they can.  Their first attempts are usually efforts to entice the child with new activities or persuade their child to become involved in the old familiar activities.  By doing this, they try to return the child to the way he or she was before the abuse.

A helpful strategy for drawing out the child is called "Reversing the Family Hierarchy" (Madanes, 1984).  In this strategy, a parent develops a pretend problem.  Children are naturally quite willing to help out the adults in their lives (Madanes,1990).  When called upon, children will do anything to help their parent "get better" and readily agree to the request.  The purpose here is to have children focus on a situation and become so involved in another's "misfortune" that they forget their own.

For example, a young boy spends more time by himself and less time with friends and family.  He sits in front of the television, but is not really watching it or he sits in his room for hours and reads or works on puzzles.  Formerly, he had played outside consistently, but now he is not interested and rebuffs friends' offers to play.

The father is instructed to pretend to be more withdrawn than the child.  He is told to sit on the couch, in the dark and breathe deeply and issue sighs of woe.  The therapist, in a light way, explains to the child that the parent is in need of assistance and asks for the child's help.  The therapist asks for input and directives on how to help the parent.  This child may suggest playing games, watching television together, going to the store, or going for walks.

During the session, the family members practice the whole sequence of events.  The father sighs and breathes deeply.  The child approaches the father and frets over him and suggests an activity.  The parent puts up a slight amount of resistance so the child becomes further involved in encouraging the father to participate.  (However, the child should not get to the point of being discouraged.)  Soon, the father acquiesces and joins in one of the activities the child had chosen.

The family is then given this assignment to perform at home at certain days and times.  By doing this with the child, the parents help the child move forward and come out of his solitude.
  

Treatment for Depression

The above technique also works well with children who are depressed.  Children showing depression exhibit tearfulness and a sense of hopelessness and helplessness.  Their appetites may increase or decrease.  Their energy level decreases and they have difficulty focusing.  They may also be described as having low self-esteem (DSM-III-R, American Psychiatric Association, 1987).  Using the technique described above, once the hierarchy is reversed, these children tend to focus on issues of planning and implementing ways to distract their parents or loved one.  They then have limited time to focus on their own depressed feelings.
  

Treatment for Anxiety

Anxiety and sleep disturbances may also affect sexually abused children.  The symptoms include tension, concern, and uneasiness about the possibility of impending danger.  Anxious children might be described as nervous, jittery or worried.  Physically, they might tremble or shake, have shortness of breath, feel dizzy, have nausea or pain in their stomach, or experience a choking feeling (DSM-III-R, American Psychiatric Association, 1987).  Parents become very concerned about these conditions, partly because it is affecting their child but also because they may be having these problems themselves.

Structured relaxation techniques may help anxious children and their parents.  Such techniques help the child to concentrate on relaxing and allow the parents to be the ones supporting and encouraging this behavior.  It puts the parents back in charge of the child's well being and makes them the experts in their child's welfare.  Because relaxation is introduced as a formal technique, the parents' expectations of helpfulness increase immensely and the child is assured that the parents can help.  Therefore, the parents are an integral part of the child's recovery.

Initially, the therapist meets alone with the parents to select a happy memory or activity that the family has participated in.  Then the therapist describes the relaxation technique to the parents, demonstrates it to them, and the parents practice the technique with the help of the therapist.

At the next session, the therapist begins and one parent repeats the instructions.  The parent tells the child to sit or lay comfortably and to close his eyes.  He talks to the child about focusing on the sound of the parent's voice and instructs the child about breathing in and out in a regular manner and paying attention to the breathing.  The parent can say to the child:

Now, I want you to lay down and put your head in my lap.  I want you to take a deep breath and let it out slowly.  That's good.  I want you to continue to breathe in deeply and exhale slowly; and as you breathe in deeply and exhale slowly, I'm going to begin rubbing your eyebrows.  First, you'll feel me rub your left eyebrow and then I'll rub your right eyebrow.  As I'm rubbing your eyebrows, your eyelids will get heavier and heavier and heavier until your eyelids simply close by themselves.  And when your eyelids are closed, it's like you're sitting in a theater watching a movie screen seeing a movie of us in a very happy place.  You can remember the last time we were at the beach playing in the water, the waves rolling in, the wind was blowing and you were having a wonderful time.  At any time you want or need to feel as good as you feel right now all you need to do is to breathe in deeply, exhale slowly, let your eyelids close and think about all of us at the beach.

The family is told to practice this regularly.  After the child learns the technique, he can be encouraged to respond to anxiety symptoms by going to his room, lying down, listening to favorite music, and thinking of the relaxing and happy image.  This technique should also help a child whose anxiety interferes with sleeping.
  

Treatment for Dissociative Reaction

A dissociative reaction in a child is most often seen as daydreaming or impaired concentration in school.  It is usually described as the child having attention problems and can be reframed as wandering attention episodes.  A behavioral technique to remind the child to refocus attention can help these children.

For example, a girl is often seen staring at the ceiling in the classroom and not hearing the instruction during parts of the school day.  It interferes with her work and grades.  The therapist is told what the wandering episodes are like.  In this case, the child says she always finds herself looking up at the classroom ceiling.  The therapist then tells the child to "blank out" and let her attention wander to the ceiling.  She is told that when her attention wanders, it is to be like an alarm (rinnnggg!!, rinnnggg!!) going off inside her head.  She is then told she will hear a warning, "I'm missing interesting things.  I want to pay attention to the interesting things that my teacher is telling us."  This can be practiced several times with the encouragement of the parents.

Thus, the child learns to recognize when her attention has wandered so that she can refocus her attention on what is happening in the classroom.
  

Conclusion

We have presented an alternative to the way many therapists treat sexually abused children.  Sexual abuse by itself does not necessitate specialized treatment.  As with other problems that bring children and their parents to therapy) it is the clinical condition that should be treated.  The therapist must focus on these conditions and address what needs to be done, rather than why the abuse occurred.  The treatment suggestions we have presented can ordinarily be accomplished in a brief manner.  These treatment suggestions include the child's parents since the parents are the child's main source of social support.  We believe that this strategy offers maximal opportunity for the child to recover from problems resulting from the sexual abuse and return to age-appropriate normal behavior.
  

References:

American Psychiatric Association. (1987). Diagnostic and Statistical Manual of Mental Disorders (Third Edition-Revised) DSM-III-R ()(). Washington, DC: The American Psychiatric Association.

Beutler, L. E., & Hill, C. E. U992). Process and outcome research in the treatment of adult victims of childhood sexual abuse: Methodological issues. Journal of Consulting and Clinical Psychology, 60, 204-212.

Caffaro-Rouget, A., Lang, R. A., & van Santen, V. (1989). The impact of child sexual abuse. Annals of Sex Research, 2, 2947.

Campbell, T. W. (1992a). Promoting Play Therapy: Marketing Dream or Empirical Nightmare? Issues in Child Abuse Accusations, 4(3), 111-117.

Campbell, T. W. (1992b). False Allegations of Sexual Abuse and the Persuasiveness of Play Therapy. Issues in Child Abuse Accusations, 4(3), 118-124.

Campbell, T. W. (1993). Parental conflicts between divorced spouses: Strategies for intervention. Journal of Systemic Therapies, 12, 27-38.

Campbell T. W. (1994a). Beware The Talking Cure: Psychotherapy May Be Hazardous to Your Mental Health (). Upton Books (SIRS Press). Boca Raton, FL.

Campbell, T. W. (1994b). Psychotherapy and malpractice exposure. American Journal of Forensic Psychology, 12, 541.

Ceci, S. J., Ross, D. F., & Toglia, M. P. (Eds.). (1989). Perspectives on Children's Testimony (). New York: Springer-Verlag.

Cohen, S., & Hoberman, H. (1983). Positive events and social supports as buffers of life change stress. Journal of Applied Social Psychology, 13, 99-125.

Cohen, S., & Syme, S. L. (Eds.) (1985). Social Support and Health (). New York: Academic Press.

Cohen S., & Wills, T. A. (1985). Stress, social support, and the buffering hypothesis. Psychological Bulletin, 98, 310-357.

Davids, A. (1975). Therapeutic approaches to children in residential treatment: Changes from the mid-1950s to the mid-1970s. American Psychologist, 30, 809-814.

Evans, I. M. (1993). Constructional perspectives in clinical assessment. Psychological Assessment, 5, 264-272.

Fisch, R., Weakland, J. H., & Segal, L. (1988). The Tactics of Change: Doing Therapy Briefly (). San Francisco: Jossey-Bass Publishers.

Gorin, S. S. (1993). The prediction of child psychotherapy outcome: Factors specific to treatment. Psychotherapy, 30, 152-158.

Haley, J. (1983). Problem-Solving Therapy (). San Francisco: Jossey-Bass Publishers.

Haley, J. (1984). Ordeal Therapy (). San Francisco: Jossey-Bass Publishers.

Hoorwitz, A. N. (1992). The Clinical Detective: Techniques in the Evaluation of Sexual Abuse (). New York: W. W. Norton & Company.

Kendall-Tackett, K. A., Williams, L. M., & Finkelhor, D. (1993). Impact of sexual abuse on children: A review and synthesis of recent empirical studies. Psychological Bulletin, 113, 164-178.

Madanes, C. (1981). Strategic Family Therapy (). San Francisco: Jossey-Bass Publishers.

Madanes, C. (1984). Behind the One-Way Mirror: Advances in the Practice of Strategic Therapy (). San Francisco: Jossey-Bass Publishers.

Madanes, C. (1990). Sex, Love and Violence (). New York: W. W. Norton & Company.

Matt, G. E., Vazquez, C., & Campbell, W. K. (1992). Mood-congruent recall of affectively toned stimuli: A meta-analytic review. Clinical Psychology Review, 12, 227-255.

Minuchin, S., & Fishman, H. C. (1981). Family Therapy Techniques (). Cambridge, MA: Harvard University Press.

Rosen, A., & Proctor, E. K. (1981). Distinctions between treatment outcomes and their implications for treatment evaluations. Journal of Consulting and Clinical Psychology, 49, 418-425.

Sarason, B. R., Sarason, I. G., & Pierce, G. R (Eds.) (1990). Social Support: An Interactional View (). New York: Wiley.

Singer, J. A., & Salovey, P. (1988). Mood and memory: Evaluating the network theory of affect. Clinical Psychology Review, 8, 211-251.

Weisz, J. R., Weiss, B., & Donenberg, G. R. (1992). The lab versus the clinic: Effects of child and adolescent psychotherapy. American Psychologist, 47,1578-1585.