consequences of sexual abuse
10.1 An individual CBT programme for sexually abused children aged 6–18 years
10.1.1 General considerations
r The therapist provides positive reinforcement for commencing therapy and attempts to establish a therapeutic alliance.
r Homework tasks are essential and provide the opportunity to develop skills.
r Homework is reviewed at the start of each session. Impediments to homework tasks form the basis of subsequent communication and problem-solving activities and success is reinforced.
r The therapist models confidence and calmness when discussing abuse-related material.
r Focus on the child’s strengths and model behavioural and cognitive coping skills.
10.1.2 Module A: groundwork (one to two sessions) 10.1.2.1 Purpose
To establish rapport and help the child feel safe. The overall plan for the treatment is explained. Information on sexual abuse and sexual terminology is provided, in order to desensitize the child to embarrassment or uncertainty with the topic.
The child will develop goals for the therapy and begin to build hope for a positive outcome.
10.1.2.2 Activities
The child is introduced to the therapy process and how she/he will learn skills to cope with negative feelings, face what has happened and learn about the link between thoughts, feelings and behaviour. The child is given the opportunity to ask questions and express uncertainty about the treatment.
Age-appropriate education about sexual abuse includes hand-outs and discus-sion on the prevalence and nature of abuse and the short- and long-term problems and post-traumatic emotional and behavioural symptoms it can cause. Informa-tion on why perpetrators sexually abuse young people might also be provided.
Information on the effectiveness of the treatment programme and how it can change thoughts, feelings and behaviour is discussed.
Within an age-appropriate framework, there is discussion and activity, such as the use of body part pictures, that explore the child’s terminology for body parts and sexual acts. The therapist provides education regarding ‘appropriate’
terminology and a consensus is developed on the terminology to be used during therapy.
An activities and worksheet folder is introduced and the child/adolescent is encouraged to identify their goals for treatment and general areas for change such as making friends and specific goals such as making one friend at school.
Discussion of the positive outcomes that would follow from achieving these goals builds hope.
10.1.3 Module B: addressing feelings (two sessions) 10.1.3.1 Purpose
To teach the child/adolescent to recognize and express appropriately a range of emotions, especially abuse-related feelings.
10.1.3.2 Activities
Emphasize both positive and negative emotions and link them to thoughts, bodily experiences and behaviour. The concept of fear as a feeling response to danger is introduced and explained.
Printed and multimedia material on feelings are used as a stimulus to generate the listing of different feelings. The child/adolescent is encouraged to give exam-ples of situations which produce both positive and negative feelings. Discussion about the various ways of expressing feelings is used to reinforce acceptable and appropriate outlets for emotions.
The notion of fear as a normal response to danger is discussed and the young person produces a list of situations which might produce fear, such as thunder.
Fear is automatic and produces three responses: fight, flight or freeze. Examples of personal experience of these responses are elicited or picture prompts are used to imagine potential responses. Role plays or story writing can further reinforce understanding.
Fear is expressed as feelings, thoughts and actions, and the child is encour-aged to generate lists of possible reactions in the three categories of ‘feel, think and do’. The child is then encouraged to add fear reactions to their abuse experience.
Explain that sometimes fear responses occur even when there is no actual danger, such as when there are reminders of their abuse experience. The child is asked to identify reminders of their abuse which trigger feelings of fear, preferably making a list using words or pictures. Many of the tasks in this session can be reinforced with homework. These sessions end in an optimistic and positive manner.
10.1.4 Module C: learning coping skills (six to eight sessions) 10.1.4.1 Purpose
To teach cognitive and behavioural coping strategies preparatory to exposure to memories of the abuse experience. This includes training in progressive relax-ation and the generalizrelax-ation of relaxrelax-ation coping skills; learning to restructure cognitions especially in relation to correcting negative attributions associated with the abuse; and learning specific mental and behavioural rehearsal skills for coping with stressful situations and integrating these strategies to handle situations that produce fear and anxiety.
10.1.4.2 Activities
The therapist outlines the cognitive behavioural coping model that addresses manifestations of fear in three categories of feel, think and do. Existing positive coping strategies already used by the young person are identified. Progressive relaxation training is introduced, modified for age, using scripts or audio- or videotapes. Feelings associated with relaxation are identified and contrasted with those of fear and anxiety. Word or visual relaxation cues are developed
which facilitate relaxation in real life settings. Relaxation exercises become a regular homework activity helped by the provision of a personalized relaxation tape made by the therapist.
The therapist explains how feelings of distress can be due to unhelpful thoughts or talk. The use of cartoons and drawings are used to identify unhelpful self-talk and the link to feelings and behaviours. A link is made to the abuse situation and the young person identifies her/his specific negative self-attributions and how these may have adversely affected their self-esteem and behaviour. These unhelpful beliefs and self-statements are challenged collaboratively with the aim of converting these into a list of positive self-statements. The thought stopping technique is explained, demonstrated and practised by the young person. Positive qualities of the young person and examples of situations that were handled well are identified. Positive self-talk and self esteem role play or writing exercises are used. Homework tasks involve recording self-talk thoughts, feelings and positive events.
The skills required to monitor feelings and ‘play the detective’ are taught and practised to enable the child to attend to and evaluate realistically their feelings.
The process of covert or mental rehearsal is explained. The child identi-fies a situation of a distressing nature and with eyes closed is encouraged to describe the situation until anxious feelings are evoked. The young person is then encouraged to continue to imagine themselves in that situation, but to picture themselves feeling calmer and overcoming the situation. Relaxation and positive self-statement skills are used.
The young person then learns about behavioural rehearsal. The young person identifies a real life situation of difficulty with another person such as a parent or friend. The young person then role plays the situation with the therapist and is encouraged to be verbally and non-verbally assertive. The therapist provides feedback and with praise and encouragement coaches the young person to become proficient and confident.
The various coping strategies of rehearsal, relaxation and cognitive procedures are applied to some fear-producing situations identified by the young person which are not related to abuse and may be further practised in homework tasks.
10.1.5 Module D: exposure to memories of the abuse experience (four to six sessions)
10.1.5.1 Purpose
To help the young person recall and describe the abuse experience and experi-ence the associated emotional responses to that experiexperi-ence, but in a supportive
environment using the coping skills he or she has learned to manage negative affect.
10.1.5.2 Activities
Review what the young person has learned about abuse-related feelings and thoughts, the specific reminders of abuse which trigger fear and their newly acquired coping skills. Now that the young person has better ways of handling fear, it is time to work on developing a detailed account of the abuse experience.
The young person is led to imagine the abuse experience. This might require writing notes, using doll play, drawing, singing, writing poetry or making an audiotape. These are all imaginal techniques and usually involve the construction of a hierarchy of events from least stressful to most stressful. This imaginal approach to systematic desensitization is linked to the progressive application of relaxation, cognitive and rehearsal coping strategies. On occasions, when there is an unrealistic avoidance and anxious response to aspects of daily life, it may be necessary to use a process of in vivo systematic desensitization to a hierarchy of situations such as approaching a park, entering the park, taking the path to the bandstand and so on.
The child usually needs to work through their memory of the abuse on several occasions.
10.1.6 Module E: dealing with disclosure (one to two sessions) 10.1.6.1 Purpose
To teach the young person how to anticipate and manage situations related to disclosure about the abuse experience.
10.1.6.2 Activities
The young person is asked to identify events since the abuse that may have caused distress, such as undergoing a medical examination or talking to the police, and, if possible, to write a story or draw a picture about this event. Explain how these situations may also generate negative feelings, thoughts and behaviours.
Cognitive restructuring or systematic desensitization with the application of coping strategies is used to overcome the negative affect associated with these remembered experiences.
These sessions might also lead to identifying feelings related to the offender.
These feelings are often complex and may be both positive and negative. It is helpful for the child to generate a list, draw a picture, write a letter or speak about all of the feelings they may have towards the offender. Emphasize that feelings of fear are reminders of the abuse experience, but do not necessarily mean that they
are currently in real danger. Discuss the importance of distinguishing between actual danger and abuse reminders of past experiences. Generate examples of actual danger such as being alone with the offender, as opposed to an abuse reminder such as seeing someone who looked like the offender. Help the child to identify safety factors in their situation at home, school and their neighbourhood such as vigilant teachers, having a mobile phone and the existence of a restraining order. Homework tasks may involve the application of their coping skills, such as using calming statements and relaxation exercises, when they have thoughts about the offender.
10.1.7 Module F: body awareness and sexuality (one to two sessions) 10.1.7.1 Purpose
To enhance an accurate and positive view of the physical self and explore sexual knowledge, values and feelings in an age-appropriate fashion. To use cognitive restructuring as a method to identify and correct negative thoughts about the body and sexuality.
10.1.7.2 Activities
Ask the young person to generate a list of questions about bodies and sexu-ality including what they imagine sexually abused young people might worry about in relation to their body. Identify any negative body and sexual develop-ment thoughts. Challenge these thoughts and develop positive self-statedevelop-ments.
Use written or multimedia information at an age-appropriate level to illustrate normal sexual development, identify the child’s own stage of development and comfortably describe the function of body parts including the genitals. Identify, perhaps through the use of life-size tracing, the parts of the body that the young person likes most.
Use written or multimedia material to discuss appropriate sexual values and behaviour including the concepts of maturity, consent and mutuality. Identify fears or worries the young person may have about sexuality. Provide information and apply cognitive and behavioural methods to cope with troublesome thoughts such as cognitive restructuring for thoughts of not wanting to grow up. Use modelling or behavioural rehearsal to teach acceptable behaviour such as neutral touching. Homework may include a review of reading and multimedia material on sexuality and appropriate behaviour.
10.1.8 Module G: prevention training and termination (one to two sessions) 10.1.8.1 Purpose
To review the knowledge gained in the programme, to work on prevention concepts, reinforce the young person’s sense of efficacy and reinforce self-protective behaviours and identify a support system.
10.1.8.2 Activities
The child is asked to recapitulate what they have learnt particularly about fear and coping strategies. Use a worksheet to identify dangerous and safe situations with other people, identify behaviours and strategies that can help deal with a difficult or dangerous situation. Recapitulate on the difference between actual danger and abuse reminders. Use behavioural rehearsal or role-playing techniques to practice protective behaviours.
Develop the use of a diary, which encourages planning and the identification of cues that signal the need to use coping skills and the daily use of strategies such as positive self-statements and relaxation exercise. The diary might also include useful community resources and contact numbers of trusted people who can help with problems.
The sessions end on a positive note with the presentation of a reward such as a bound copy of important printed material from the sessions, or a gift that emphasizes the qualities of the young person or the presentation of a graduation or ‘bravery’ certificate.
10.2 Conclusions
A manual-based structured CBT programme for young people suffering the emotional and behavioural effects of child sexual abuse encourages them to confront their abusive experiences and provides a number of coping skills to enable them to deal with their disturbed emotions. The follow-up of sexually abused children who have been treated with CBT indicates that therapeutic gains are maintained, although long-term follow-up studies are required to determine if the long-term adverse mental health consequences of childhood sexual abuse in adults are to be prevented (King et al., 2000). However, current evidence suggests that CBT should be the first treatment offered to young people suffering the emotional and behavioural consequences of sexual abuse.
10.3 R E F E R E N C E S
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