Seminar on Child Sexual Abuse

Seminar on Child Sexual Abuse

Ralph C. Underwager
and
Hollida Wakefield

Hungary
October, 1996

VI. Effects and Treatment of Victims

A. Effects of sexual abuse

1. Sexually abused children vary widely as to how the abuse affects them. Some children are relatively unaffected, some show short-term effects, some are more seriously affected.

2. Research on the effects of sexual abuse generally use clinical samples which cannot be generalized to the entire population of sexually abused children.

3. Contrary to what most people believe, the long-term effects of sexual abuse are not nearly as severe as is often assumed (Levitt & Pinnell, 1995; Rind & Harrington, undated).

a. The effects of physical abuse and neglect are likely to be more serious and generate more long-term damage (Ney, Fung, & Wickett, 1994).

b. When family dysfunction is controlled, the effects of sexual abuse wash out. This is because both extrafamilial and intrafamilial sexual abuse are closely associated with families that are dysfunctional and pathological (Alexander & Lupfer, 1987, Beitchman et al., 1991, Levitt & Pinnell, 1995; Nash et al., 1993).

3. Some factors seem to be associated with greater harm.

a. Because of the difficulties mentioned above, this does not in any way establish a direct cause and effect link (Nash, Zivney, & Hulsey , 1993).

b. Also, there is no contributing factor that all studies agree on as being consistently associated with greater harm.

c. Many studies report greater harm with use of force, genital as opposed to other types of contact, sex with the father or stepfather, and long duration of repeated abuse.

d. Studies assessing the effect of age of onset have contradictory results.

4. A supportive environment, including a supportive, functional family, is associated with less harm.

B. Treatment for sexually abused children

1. Role of the therapist vs. role of the evaluator

a. The professional conducting the evaluation as to whether abuse happened should not be the professional who provides treatment for sexual abuse. The roles are different and are contradictory in many respects.

b. Therapy should never be used to make a determination as to whether, in fact, abuse happened.

c. A child should not be given therapy for sex abuse until there is a determination that abuse has occurred (Ceci, 1994; Gardner, 1992; Wakefield & Underwager, 1988). If the child needs treatment before a judicial determination, any treatment should address whatever behavioral problems the child is having, but not focus on sexual abuse.

d. If a child is in therapy prior to such a determination, the child may ask questions or talk about sexual abuse. Give careful responses that will not contaminate the child's memory and answer questions honestly. Remember that the goal of therapy is to restore the child to normal developmental growth as quickly as possible. This can be done without focusing on abuse.

2. Begin with a careful individual and family assessment.

a. Children react to abuse differently. There are no typical symptoms of the sexually abused child. Some children may need only reassurance and support, but not long-term therapy. There is no such thing as a child sexual abuse syndrome that is diagnostic of children who have been sexually abused.

b. The assessment should include some assessment of the child's developmental level, descriptions from the parents as to problem behaviors, and information about the nature of the abuse.

c. Emphasize measurable, objectively described behaviors and not hypothesized internal states.

d. Evaluate the extent to which the child's problems are the result of the investigation process and the child's family's reactions to the disclosure. This includes interviews by law enforcement and social services, foster home placement, genital examinations, publicity about the case in the media which results in the child's peers knowing about the abuse, foster home placement, and termination of contact with a parent.

e. In intrafamilial abuse, assess the degree of danger for future abuse. In the United States, this is not likely to be a problem since either the perpetrator or the child will be removed from home.

f. Assess the family system and the strengths and problems. This can be done through behavioral observation of the family in interaction as well as through individual assessments of all members of the family. Stress and rely upon valid and reliable statistical and actuarial methods as much as possible. These measures may include personality, intellectual functioning, and strengths and resources.

3. Include standardized measures of the child's problems.

a. For example, the Child Behavior Checklist (Achenbach & Edelbrock), the Louisville Behavior Checklist (Miller), and the Personality Inventory for Children (Wirt, et al). These are parent-report checklists that differentiate between children with psychopathology from children in the general population and provide descriptive information of the child's assets and problems.

b. Do not use drawings for anything other than interview aids and conversation starters. There is no evidence that the symbolic sign approach to children's drawings is reliable or valid.

4. Do not convey to the parents or the child that the child is likely to be seriously and perhaps permanently damaged by the abuse.

a. The exaggerated emphasis on the harmful effects of abuse can leave the family hopeless, fearful, and anxious. This can become a self-fulfilling prophecy.

b. If long-term, intensive therapy is given to a child who does not need it, a relatively brief, although unpleasant event, in the child's perception, may be blown up into a major catastrophic event. Misguided therapy may teach a child to be a lifelong victim.

5. If a careful assessment indicates no problems, do not give the child long-term intensive therapy. Reassure the child and be in a monitoring role with the child and parents. If problems appear later, they can be addressed.

6. Family involvement is essential.

a. With incest, treatment of the child must be coordinated with treatment for the offending and nonoffending parent.

b. In extrafamilial abuse, the parents and other family members should be actively involved whenever possible. Do not treat the child apart from the parents.

c. With younger children, the focus should be on helping the parents learn effective ways of responding to the child's problem behaviors.

d. Parents may attend to problem behaviors that they believe were caused by the abuse. This often has the effect of increasing the frequency of the behaviors. Therefore, it is important to work with the parents on effective ways to respond to problem behaviors.

7. The type of therapy for children which has demonstrated efficacy is cognitive-behavioral (Casey & Berman, 1985; Weitz et al., 1987, 1995; Weitz & Weiss, 1993).

a. Specific problems are targeted and strategies are developed for working on them.

b. The treatment strategies will involve step-by-step, daily activities that help the child and the parents address the child's problems.

8. Child therapy as is practiced in most clinics in the United States is not effective according to the outcome research (Weitz et al., 1992; Weisz, Donenberg et al., 1995; Weitz & Weiss, 1993)

9. Play therapy

a. This is the most frequent approach used in the United States. Sometimes, it is termed "disclosure-based, play therapy."

b. Children are encouraged to express their feelings and act out the abuse in play sessions. The therapists may use drawings, dolls, puppets, and sand tables. Their play, in turn, is interpreted as reflecting actual things that have happened to them.

c. There is no research on play therapy that supports its use with sexually abused children (Campbell, 1992a; White & Allers, 1994).

10. View the child as an active participant in solving her problems and help the child modify her behavior.

a. Do not treat the child as a passive victim.

b. Give the child the message that, although she is not responsible for the abuse, she is responsible for knowing right from wrong and for getting help if she is abused again.

c. The child can learn more effective ways of dealing with whatever problems she now has.

10. Cognitive-behaviorally focused group therapy can be helpful with older children, since meeting other children who have been abused can be helpful.

11. Children may show opposition and resistance to therapy (Haugaard, 1992). This should be handled by exploring and then gently challenging false beliefs about therapy that the child may have. These false beliefs include:

a. The child may think she was brought to therapy because of a personal defect or illness she has that caused the abuse.

b. The child may see therapy as a type of punishment. "Why must I come here when it was my father who did everything wrong."

c. The child may believe he must go to therapy because people think he will become a child abuser himself later in life.

12. Family therapy is recommended

a. This was the first approach used to respond to sexual abuse.

b. The Child Sexual Abuse Treatment Program (CSATP) was developed by Giarretto (1980) in Santa Clara County, California beginning in 1971. It succeeded admirably. 90% of the children were returned home within the first month and 95% eventually. There was no recidivism reported in more than 250 families.

c. Unfortunately, as the emphasis in the United States shifted to prosecution and demonization of alleged perpetrators, this established and demonstrated program dropped out of use. It combined individual treatment, family therapy, and marriage therapy and emphasized the positive contributions strengths can make to growth.

d. This was the approach Dr. Underwager first used in 1953 when he encountered a case of incest. We also used this approach with the cooperation of the authorities until about 1977 when it became difficult to pursue family therapy and reunification of families.

e. The advent of a systematized child protection system and the emergence of a corps of protection workers moved treatment n a different direction.

13. Major premises of family therapy

a. The family is viewed as an organic system. Family members assume behavior patterns to maintain system balance (family homeostasis).

b. A distorted family homeostasis is evidenced by psychological/physiological symptoms in family members.

c. Incestuous behavior is one of the many symptoms possible in troubled families.

d. The marital relationship is a key factor in family organic balance and development.

e. Incestuous behavior is not likely to occur when parents enjoy mutually beneficial relations.

f. A high self-concept in each of the mates is a prerequisite for a healthy marital relationship.

g. High self-concepts in parents help to engender high self-concepts in children.

h. Individuals with high self concepts are not apt to engage others in hostile-aggressive behavior. In particular, they do not undermine the self-concept of their mates or children through incestuous behavior.

i. Individuals with low self-concepts are usually angry, disillusioned, and feel they have little to lose. They are thus primed for behavior that is destructive to others and to themselves.

j. When such individuals are punished in the depersonalized manner of institutions, the low self concept/high destructive energy syndrome is enforced. Even when punishment serves to frustrate one type of hostile conduct, the destructive energy is diverted to another outlet or turned inward.

14. Overall the continuing research shows that family dysfunction is the major issue in causation of abuse, physical, emotional or sexual, and any long-term negative effects. Children growing up in intact, functional and supportive nuclear families are significantly less likely to report any form of abuse (Gaudin et al., 1990; Mullen et al., 1996)

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