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Home > Treatment for Abused and Neglected Children: Infancy to Age 18 > Treatment for Abused and Neglected Children: Infancy to Age 18 : Therapy
Treatment for Abused and Neglected Children: Infancy to Age 18
TherapyTherapy is the art and science of helping children make sense of their feelings, thoughts, and behavior and learn how to control their behavior and improve interactions with others. It is art because it calls on the therapist's creativity, intuition, and spontaneity. It is a science because therapy with abused and neglected children is based on theory, research, and clinical studies. The goals that need to be accomplished and the techniques or interventions that help children address and grow beyond the experience of abuse and neglect are gleaned from theory and clinical literature, research, and experience. This chapter addresses theoretical orientations to therapy, the role of the therapists, rights and responsibilities in therapy, the therapeutic process, the stages of therapy, and treatment modalities. Some of the most common treatment issues and concerns about children who have experienced maltreatment are discussed in a later chapter. Theoretical Orientations A number of theoretical orientations offer useful insight for working with abused and neglected children. Developmental theories deal with the following:
Interpersonal theories include:
Cognitive and behavioral theories explore:
System theories deal with:
Abuse and victimization theories explore:
Role of the Therapist The therapist has an important role in helping a child recover from the effects of abuse and neglect. The therapist serves a number of functions, including:
The therapist's initial function is to establish rapport and develop a trusting relationship that will help the child address the thoughts, feelings, and behaviors that are generated by abuse and neglect. The therapist promotes the child's awareness and understanding of abuse dynamics, encourages growth and development beyond the role of victim or the inappropriate identification with the offender, and supports the child's individuality and personal integrity. The therapist teaches the child to care for him/herself, think about his/her behavior, and make choices that maximize his/her safety. The therapist also needs to help the child regain trust, faith, and investment in meaningful relationships. As an adult, the therapist models appropriate behavior including nurturing, affection, and the expression of feelings. The therapist gives the child the opportunity to explore issues of trust, acceptance, affiliation, and emotional intimacy. The child can integrate the therapist as a role model for safe and nurturing relationships. The therapist also shares the child's hope, excitement, and curiosity about life in order to help his/her client reinvest in his/her future. The therapist models and maintains good clinical boundaries. He/she understands the vital bond between child and parent and does not attempt to take the place of the parent. Instead, the therapist helps the child and parent interact appropriately and offers alternative problem-solving models for parent-child relationships. The therapist also helps the child to be as realistic and practical as possible when relating to parents with problems. It is a difficult task to help a child to be realistic, while not taking away his/her hope for change and improvement in his/her parents. Although clinical interventions and psychotherapy with parents is beyond the scope of this manual, it is vital that every effort be made to improve and maintain the child's relationships with family members. Children need to express a full range of feelings regarding their family members. The therapist can be more helpful by remaining neutral and empathetic to the child's situation than by taking angry and punitive stances toward parents and unavailable family members. Conjoint therapy with a parent and child, family therapy, or role-playing family interactions when no parent is available can help the child attain a realistic and pragmatic approach to his/her parents and family. Formal training in the processes and dynamics of these various treatment modalities is encouraged prior to their use. One of the most important functions of the therapist is to facilitate the child's investment in a positive and protective support system that continues to be available to the child when therapy ends. Children who have been abused or neglected may not know how to interact appropriately with people who could be supportive, helpful, and appropriate for social interaction. Children need to learn social and interpersonal skills that will facilitate their interaction with peers and adults. Individual therapy can begin this process by offering a supportive environment in which to address the child's experience, needs, and abilities and by allowing the child to learn to interact appropriately with an adult. Therapy offers the child an opportunity to verbalize and explore many of the issues or concerns typical of victims of abuse and neglect. It also offers the child an opportunity to practice expressing feelings and to learn behaviors that can generate appropriate responses from adults and peers. Group therapy can further this process by allowing a child to participate in a group of his/her peers who have had similar experiences. This group experience can help the child realize that many of his/her behaviors or reactions are typical for children who have been abused or neglected. Group therapy allows the child to practice and modify many of the skills he/she has learned in individual therapy. These skills include listening, sharing, responding with interest and empathy, and demonstrating age-appropriate concern and affection. It is much easier to insert corrective information or action when a therapist witnesses a problematic interaction than when he/she learns about that problem later. Many of these skills that can be utilized in a neighborhood or school setting increase the child's likelihood of finding appropriate and responsive friends. Participation on team activities can increase cooperation and appropriate social interactions and can offer esteem-building experiences for the child. Participation in social and school groups allows the child an opportunity to apply and practice his/her acquired social skills and relate to other children as a peer rather than as a victim of abuse or neglect.141 Clients' Rights in Therapy Children, and all consumers of therapy, have certain rights that must be maintained during the course of therapy. These include the right to an abuse-free environment, the right to ask questions about therapy and receive an answer that they understand, the right to expect that therapy is helpful, and the right to be treated as a unique individual. Abuse-Free Environment An abused child comes to therapy with the knowledge that some adult misused his/her knowledge, power, and experience to take advantage of the child. As an adult, the clinician is in a position of implied power and has knowledge and experience that can help the child. This power, knowledge, and experience differential needs to be clarified and used appropriately. The role of the therapist is to protect the child; listen and respond to the child in a manner that generates growth and development; model appropriate adultchild interaction, and help the child learn safety, protection, problem-solving and communication skills. The therapist will need to set appropriate limits and adhere to boundaries that protect the child as well as him/herself. A national survey found a significant number of cases of therapistclient sexual intimacies involving minor children.142 The ages for boys who were abused ranged from 1 to 16, with age 12-1/2 the average. The ages for girls who were abused ranged from 3 to 17, with 13-3/4 the average. This is an issue that must be monitored carefully. Children must also be made aware that there is possibility of being sexually abused by a professional. Therapists must report this type of abuse to the proper authorities. Protection and Limit-Setting The therapist may need to define appropriate and inappropriate behavior for the child. A child who attempts to expose his or her private body parts needs to be stopped. The therapist needs to explain that behavior is not necessary or acceptable. The therapist can explain that children only need to show their body parts under special occasions such as medical exams. Attempting to touch the therapist's private body parts or peeking under clothing also needs to be defined as unacceptable behavior. Natural consequences, logical consequences, shortening the session so the child can behave appropriately for a short period of time, taking a "time out" to relax, or stopping the session are all methods that can be used effectively with children. Threats to end the session or to discuss a child's behavior with the parents are usually ineffective. However, the child's parents need to be informed of the therapist's plan for addressing problematic behavior. The therapist will need the parents' cooperation, support, and willingness to follow up with a discussion. Parents will also need to support the need for therapy and insist that the child return to subsequent sessions. It is important to clarify the rules and discuss the consequences with the child so that he/she understands the intention and purpose of discipline. This discussion should take place before the therapist imposes any consequence. It should be made clear that the therapist will continue to work with the child to help him/her use therapy. The overriding goal is to demonstrate to the child that no problem or behavior is so disturbing that it cannot be addressed. Within the therapeutic relationship, a child will often attempt to create the same power structure found in the abusive family. Many children can be demanding and authoritarian, and they may make threats or suggestions that challenge the therapist's authority and role. Usually, these actions are the child's attempts to find out how the therapist will respond. Often, a therapist will feel angry or powerless and may feel that he/she is being bullied or manipulated by the child. It is important for the therapist to identify the type of behavior that elicits these kinds of reactions. Feelings about the behavior need to be expressed to the child with the therapist also demonstrating problem-solving responses to that behavior. Thus, the child can become aware of how his/her behavior may generate strong reactions in others and begin to expect consequences that do not include abuse. At these times, clinical supervision is particularly helpful to the therapist in processing his/her reactions to the child/family and in developing strategies for future sessions. Sometimes a child does not have the skills to develop a relationship based on reciprocal interactions and respect. In these cases, the therapist can educate the child about relationships, manners, and social skills. Terminology and Communication The therapist needs to use words and terms that are understandable to the child. A 3-year-old child will need to hear different words and phrases than a teenager. It helps to be able to understand and utilize many different developmental and experiential languages in order to translate psychotherapeutic concepts into explanations that make sense to children. A therapist who works with abused and neglected children need to use words and terms that accurately describe abuse and neglect. Words and expressions that either minimize or overdramatize the experience can create the impressions that the therapist just doesn't understand the child's situation. Exaggerated statements, such as "Well, you survived abuse; you can survive anything," or "I'm so mad at your dad for doing that to you," say more about the therapist than about the child's experience. Categorizing and reacting to the child's experience or feelings before the child has had a chance to express him/herself often confuses the child or elicits a response the child feels is expected by the therapist. It is often more productive to ask the child to describe what happened and how he/she felt about the experience. The therapist should then help the child come to his/her own estimations of the experience by asking the child if the experience was helpful or hurtful, happy or sad, scary or pleasant, or any combination that helps the child identify and express his/her feelings. The therapist can ask, "How do you feel about that?" or "Do you ever feel angry about what happened?" or "What would you say to a child who was in that situation?" The therapist can also help the child talk about the experience by asking "What is the most frightening thing that ever happened to you?" or "When was a time that you felt strong and powerful?" In this way, the therapist can get a sense of the child's inner world and gain some insight into the child's thoughts and feelings. A willingness to entertain the possibility that "bad" or harmful experiences can happen to children allows a therapist to attend to the indicators of abuse and neglect. The therapist's ability and willingness to ask about abuse and neglect gives children permission to talk. The therapist's ability to explore the experiences related to abuse and neglect, including any pleasurable feelings associated with sexual abuse, allows the child to evaluate and correct any distortions and inaccurate perceptions he/she may have about acceptable or unacceptable behavior. The child also learns to manage his/her fear, anxiety, sense of powerlessness, and anger. The therapist needs to be able to talk explicitly about sexuality with the child, the family, and with other professionals.143 Therapists who work with children who have been sexually abused need to feel comfortable talking about the maltreatment, feelings of shame, injuries, secondary gains, sexuality, and sexual feelings. It is important for the therapist to be able to explain these processes to the child and the parents in language they can relate to and understand. A therapist who is comfortable clarifying adolescent slang terms or a young child's descriptive phrases for his/her body parts or behaviors will help the child feel comfortable when talking about a difficult subject. Information Children, as do all clients, have the right to ask questions about their treatment and receive answers that make sense. This allows them to experience some sense of control in the therapeutic process, something they did not experience during the abuse. This means speaking a language that children and parents understand when discussing symptoms and effects of abuse and by refraining from using therapeutic jargon or terminology that is not familiar to most clients. Children need to have their symptoms explained to them in developmentally appropriate language. Often, metaphors or examples are helpful for explaining the repercussions of abuse or neglect. Clients need to have a clear answer to their questions and therapists can fulfill this need by asking the child or parent if the answer was helpful to them. Helpful Interventions In addition to information about the purpose of therapy, the therapist needs to tailor interventions to the client's needs and abilities. Interventions must be useful to the child and parent or they will lose their motivation to attend the sessions. Clarifying the purpose and intent of the intervention and making it relevant to the child's current situation are two methods that facilitate the client's interest and involvement in therapy. Asking the child or parent to evaluate the effectiveness of therapy also helps the therapist learn if the interventions are useful. Individuality Children and parents have the right to be treated as individuals who have issues and experiences that are unique to their experience. By making assumptions or telling the client how he/she feels, the therapist overlooks the client's need to be treated as a special person. Asking the client to confirm or deny a hypothesis helps the client feel that he/she is part of the discovery process. Mentioning that some victims have felt a certain way about what has happened to them can give a child permission to consider if he/she feels that way too. Telling a child how all victims think, feel, or behave is presumptuous and decreases the child's sense of integrity and individuality. Therapist Responsibilities There are certain responsibilities that the therapist must fulfill that need to be clarified and discussed with children and parents. These responsibilities include client confidentiality and the therapist's reporting requirements, clear discussion regarding eligibility and payment for services, specific appointment times and cancellation policies, and periodic discussion regarding the length of therapy and the need for services. Confidentiality Clients need to trust the therapist, feel free to confide information and concerns, and feel comfortable exploring difficult issues and subject matter. Explaining different forms of confidentiality (e.g., doctorpatient, attorneyclient, priestparishioner) to children and parents will facilitate their understanding of the scope and purpose of treatment. In statements about confidentiality, therapists should be certain that their clients are aware that the following must be reported by professionals (as specified by State law) if they are suspected:
The therapist needs to tailor his/her explanations about reporting responsibilities to the child's ability to understand what needs to be done. For example, a therapist might tell a young child that part of his/her job is to make sure that the child is safe and that no one is hurting the child or touching him/her in ways that are wrong. The therapist needs to clarify with the child the types of touching that are inappropriate and make sure he/she understands the concept of inappropriate or hurtful "touch." There are many books about safety, touch, and prevention that can be useful for teaching this concept. The therapist should explain that if the child says that someone is hurting him/her, the therapist will tell someone, such as the police or caseworker, so that the abuse will stop. The therapist can reiterate that it is not "ok" for someone to hurt or abuse a child, and that it is important for the child to tell someone if he/she needs help with this problem. It is important that the child know that the therapist will not disclose information without notifying the child of the need to do so. It is also important that the child understands that the confidentiality privilege is held by the parent or adult guardian; the therapist will not keep secrets about the child's safety and well-being. However, parents do ask about therapy and want to know how their child is doing and if their child is making progress. The therapist can explain to the child and to the parents that he/she will update the parents and keep them aware of the child's progress in therapy by talking about the issues that are being addressed. The therapist can also help the child learn to talk to the parents about certain topics and concerns by having the child present during discussions about the child's progress with the parents. A child also benefits from knowing that information will not be discussed with his/her friends or acquaintances. In small towns, or even in large cities, it may be important to discuss with the child what kinds of behavior would be appropriate if the therapist and child meet in a public place. It is especially important to discuss confidentiality when a child in therapy may be involved in activities, such as sports or dance, in which the therapist's family members also participate. In such cases, it is important to respect the child's statements regarding privacy and his/her need for anonymity while maintaining the importance of the therapeutic relationship. Often, a child will feel more comfortable acknowledging his/her therapist in public after he/she has been in therapy for a period of time, and what initially seemed problematic is no longer an issue. The child may have disclosed his/her situation to enough friends that he/she is no longer self-conscious, or the child feels secure enough to acknowledge the therapist, wave, and move on to a more compelling activity. Adolescents may appreciate knowing that the therapist will not approach them in public or discuss the therapy outside the therapeutic setting. An adolescent may feel more comfortable if he/she knows that he/she does not need to acknowledge and greet his/her therapist if they should meet in a public place, especially if the therapist is with friends or family members. Children may also need to know that the therapist is not available for social activities or to fill the role of foster parent or friend. The therapist is an ally, resource, and role model for appropriate adultchild relationships; he/she is a professional who maintains appropriate boundaries and abides by rules and regulations. Release of Information Children often feel more comfortable talking about their issues and behaviors when they know that the therapist does not talk about his/her client outside the treatment setting. Only certain professionals, such as caseworkers or other professionals working with the family, should be privy to knowing if the child is in therapy. This information is exchanged after a release of information has been signed by the appropriate person, either the child or the child's legal guardian. Issues regarding access to the client's files need to be discussed, including the possibility of information being subpoenaed in the event of a criminal or juvenile court investigation. Clarification of Fees and Services Therapists need to be clear and specific about charges for services, including fees for written reports, court involvement, and extended telephone conversations. It is helpful to have written agreements with clients and referring agencies (e.g., city and county government, CPS, foster care, or adoption) about fees for services, sliding scales, billing procedures, and cancellation policies. A periodic review and evaluation of the fees that are owed for therapy allow the client to plan for payment and make decisions that are responsible and practical. Each State has specific rules and regulations about how old a child must be before he/she can contract for services. Clients need to know the date and time of their next appointment. The therapist needs to explain the cancellation policy and the impact that cancellations have on the client's access to services. The therapist also needs to give advance notice when he/she will not be able to meet with the child. Except in emergencies, a notice of at least 1 week allows the client to prepare for the therapist's absence. The therapist has a responsibility to inform the client of planned vacations or leaves of absence and allow enough time for the child to explore any feelings that may be related to interruption of therapy. The therapist may want to make arrangements for a colleague to be available if the child needs attention. This consideration enables the child to feel confident that his/her therapeutic needs will be met and that his/her needs are important. Evaluation of Progress The therapist has a responsibility to discuss the approximate length of time the child or parent may require therapy. The therapist also needs to allocate time with the child or parent/guardian to evaluate the need for continued service. Premature termination can be damaging to the child or adult; likewise, prolonging therapy beyond the client's need for treatment is also unethical. Periodically discussing the goals and objectives of therapy and evaluating progress helps the client feel that he/she is making progress and is capable of making decisions and accomplishing the tasks of therapy. The Therapeutic Relationship A number of factors contribute to a successful therapeutic relationship with a child. The following concepts are especially important in developing the kind of relationship that supports a child's exploration of the issues related to abuse and neglect. Trust Trust is a difficult issue for many abused and neglected children. A child who has been physically or sexually abused by a known or trusted person may be cautious in developing relationships. An abused child needs to form a trusting relationship with the therapist; that relationship must be secure enough to allow the child to begin to explore the actual abuse. The establishment of such a relationship requires great patience from the therapist, who may feel pressure from other parties involved with the child (e.g., CPS caseworkers and parents) to "make the child deal with the ... abuse" before the child is ready to do so.144 A child will test the therapeutic relationship, calling upon the therapist to repeatedly demonstrate that he/she is willing to respond and attend to the child's needs and behaviors. Safety Two very important goals in helping children recover from abuse and neglect relate to their future safety:
Attending to the child's physical safety and emotional safety during therapy helps the child begin to address these issues and fosters the development of the therapeutic relationship. Physical Safety Physical safety is often missing from the abused or neglected child's experience. Parents or caretakers may not have paid attention to the child's environment or behavior that was dangerous to the child's safety and well-being. Thus, physical safety in the therapy room and during the session is often necessary and symbolic for the child. Abused and neglected children often come to believe that they are unworthy of attention or that their safety and protection is not important. Some children develop a facade of invulnerability and take risks that can be dangerous or life threatening. Abused and neglected children may not care about the outcome of their behavior or may try to hurt themselves. Some children may not have learned to recognize that some actions and behaviors are dangerous and life threatening. Assessing the child's self-destructive behaviors and need for protection is an ongoing process. A young child, or a child with limited experiences or capacity to process information, may seek protection from the therapist as a primary means for establishing trust and a sense of security. Physically abused children may use provocative behavior to test the therapist to see if the relationship will include physical pain or punishment. Abandoned or neglected children may be surprised to find that the therapist is capable and willing to pay attention to their needs and behaviors. Sexually abused children may behave in a seductive manner or make inappropriate statements or comments to test the therapist's boundaries and reactions to see if he/she will respond to the child in a sexual manner. The therapist needs to assure the child's physical safety in the following environments:
Emotional Safety A child separated from his/her family, or whose family has been disrupted by the discovery of abuse or neglect, needs to focus his/her energy on determining what will happen next and on maintaining emotional equilibrium. Some children who have experienced a loss may feel frighteningly sad, alone, and needy. Other children may feel strongly hostile toward themselves and others. Other children may have feelings of despair, worthlessness, and defectiveness. Schmale and Engle add a fourth state that is much less intense in emotional tone and more energy-conserving.146 This state is characterized by withdrawal and vague sensations of numbness, emptiness, and hypochondriacal concerns. These various stances may indicate that the child's energy for responding and interacting is depleted. The child needs to feel that his/her world is safe and somewhat predictable before he/she will have the physical or emotional energy to attend to the tasks of therapy. In such cases, the therapist or other professional can use the following to help children feel emotionally safe:
It is important to identify and support the methods or strategies that the child uses to care for him/her self during and after the abuse. A child can begin to take pride in those attempts and recognize that he/she did the best he/she was capable of doing in a difficult situation. This supports the child's attempts at managing an unmanageable situation and allows the child to hear that his/her attempts were important and worthy of recognition. When a therapist identifies and focuses on a child's weaknesses or inadequacies, the therapist loses a means of connecting with the child based on strength, respect, and esteem. The therapist also risks forcing the child to deny or defend his/her thoughts, feelings, and behaviors. As a result, the child may become entrenched in counterproductive behaviors and may resist intervention. Pacing the exploration of the abuse over a period of time and placing the abusive experiences in the context of the child's overall life experience is more therapeutic than listing all the details and memories in one or two sessions. Most children will not have access to all the details or memories on demand and it is overwhelming for a child to confront the entire abuse experience at one time. Most children will resist. A therapist monitors and addresses emotional safety by paying attention to the clues the child gives about his/her ability to manage his/her feelings and behavior during therapy. A child will not benefit from being pushed to his/her emotional or cognitive limits. When a child is pushed beyond his/her cognitive/emotional limits, he/she will have little or no energy left to soothe or comfort him/herself. The child may demonstrate this depletion of ego strengths or defenses by regressing, acting out at home, or refusing to participate in therapy. The following clues may indicate that the child is having difficulties with the subject:
The therapeutic experience can be organized so that it does not overwhelm or exhaust the child. Some ways in which the therapeutic session can be structured are as follows:
Identifying and attending to life experiences that were not abusive or neglectful is also an important part of therapy. This helps the child place the harmful experience in context and shows that maltreatment is only one of many factors or experiences that has impacted his/her life. The child then can identify skills and arenas that he/she is competent enough to manage or master. Focusing on both positive and negative experiences can enhance the child's sense of self. Attending to life experiences that do not include being abused helps the child expand his/her sense of self and identity. This allows the child to integrate the experience into an overall sense of self that is not based solely on victimization. It also initiates the grief process that many children need to experience in order to let go of old images, expectations, behaviors, and feelings. Resistance Many behaviors that are initially perceived as resistance are really behaviors that are geared to monitor and manage anxiety generated by recall of the abuse experience. Fidgeting, fooling around, interrupting, asking inappropriate questions, and straying from the topic or task all need to be considered as possible coping behaviors that help a child disengage from his/her painful feelings and thoughts generated by the abuse. The ego defenses or defensive maneuvers that a child uses to protect him/herself from overwhelming stimuli or memories related to the abuse experience need to be acknowledged and used so the child feels validated, capable, and able to survive in the best way he/she knows how. A child seldom lets go of a defense mechanism, a defensive shield, or protective maneuver simply because he/she is told to do so. Tailoring interventions that facilitate the child's ability to process the experience and manage the anxiety and stress that are generated are important. A child will change his/her behavior when he/she feels capable of managing his/her world without that behavior. Most children will often do this at their own pace. A child who is not willing to participate in therapy will not benefit from the therapeutic experience. However, there are many ways to help a child feel more comfortable about participating in therapy. These include the following:
It is important to note, however, that not all resistant behavior means the child is unwilling to participate in therapy. Furthermore, the child may not understand what is expected of him/her within the therapeutic relationship. The child will benefit from clear descriptions of the purpose and benefits of therapy as well as clarification of how to think about and respond to questions, including the options of "not knowing" or "not wanting to say (yet)." It is also helpful for the clinician to explain and delineate appropriate behaviors in therapy, including appropriate therapistchild behavior. The clinician should also explore any fears or concerns that the child might have about therapy. Organization and Structure of Sessions The organization, structure, and process of the therapy can make major contributions to the therapeutic relationship. Developing a format for the session, clarifying the use of time within the session and attending to content and process experiences are important in effective therapy. Format Developing a format or routine for the therapeutic session allows the child to accomplish the tasks of remembering, talking about the abuse, and discharging accumulated emotions. The child will begin to depend on the format established by the therapist. The format helps the child organize his/her thoughts, feelings, and behavior and feel comfortable about discharging his/her emotions, exploring their circumstances and history, and learning how the abuse has affected him/her. It is important to clarify the topics that will be covered, such as "What happened to you, and how you feel about it?" The therapist needs to emphasize repeatedly that he/she is there to help the child. The therapist can tell the child that his/her role as therapist is to help the child with any questions or concerns he/she might have about the abuse. This allows the child to begin to expect help from the therapist and to challenge the therapist when the child does not feel that the therapist is being useful. Clarifying how time will be used within the therapy session is also important. Use of Time Most therapy is organized within a specific time frame, usually the therapeutic hour. Within this time frame the therapist needs to accomplish the following:
The therapist and child need enough time to reestablish rapport, catch up on what has happened during the week, discuss and evaluate the work done in the last session, address current issues relevant to the child's growth and development, discuss and explore issues relevant to the abuse or neglect, and generate closure so the child can function effectively after completion of the therapeutic session. The therapeutic session should include time to organize the new information gleaned from the session and discharge some of the emotions that may have been generated during the session. Developing a pattern of interaction that facilitates the beginning, middle, and end of the session is a useful tool for socializing the child into the therapeutic process. Opening and closing rituals can facilitate the process of disclosure and help the child manage his/her emotions. By turning on the light in the therapy room, pushing the young child's chair in and making sure he/she is safe and comfortable, asking an adolescent how he/she feels, the therapist demonstrates rituals that connote to the child that the session is going to begin. Closing rituals help the child "put away" the work completed during the counseling session. Closing rituals symbolize that the work of therapy, including the remembering, reexperiencing, and processing has been accomplished. The child can then move on to routine tasks and activities. Putting toys away symbolizes that the therapy session has been concluded. When a child has used anatomical dolls for demonstration or learning about body parts, it is important to reclothe the dolls and put them in a location that the children notes is safe. Often, a child will want to separate the doll that represented him/herself in the demonstration from the doll that represented the abuser. Allowing the child to determine where the dolls need to be placed in order to be safe can symbolize to the child that he/she determine what needs to be done so the child can be safe and protected. Asking the child what he/she did in therapy and helping the child identify the issues he/she explored leaves him/her with a sense of accomplishment. Asking an abused or neglected child if he/she has any questions can give the child a sense of control over the final topic to be discussed in the session. It also allows the child to seek information that may not have been addressed during the session. When it becomes a routine, the question-and-answer period reminds children that the session is almost over. When the session has been concluded, the therapist can say: "I am going to turn off the light and close the door on the work we have done today." Some children will want to turn off the light and shut the door themselves. The therapist may want to remind the child of what to do in order to have a safe and happy week, such as "Tell someone if you need help." Content The content of sessions includes the discussed topics, the details of the conversations between child and therapist, and the information the child shared with the therapist about the abusive or neglectful incidents. Exchanging information and helping the child feel comfortable about recalling details of the abuse or sharing feelings about the experience is the cognitive work of therapy. Addressing the facts of the experience helps the child gain insight and perspective about the abuse or neglect. Process Process focuses on the child's interaction over time. It attends to the ways in which the child invests and reacts to the relationship with the therapist. The child's behavior and ability to interact with the therapist change over time. During the early phase of therapy, the child may be anxious and have difficulty attending to content-related tasks. The child will need to be encouraged and reinforced for participating in therapy. During the middle phase of therapy, many children express their appreciation of and dependency on the therapist. The child may experience feelings of abandonment or rejection when the therapist is not available for a session. During this phase, the difficult work of internalizing role models and grieving for losses is completed. When the child enters the termination phase he/she is investing in outside relationships and developing interests in activities that may interfere with therapy. The children may need to renegotiate the session time when it interferes with a group or school activity. This investment in activities and relationships in the "real world" is an indication the child has benefitted from the therapeutic experience. He/she has learned and is willing to trust that there are people who can and will respond to him/her in a satisfying manner. This coming together and separation is a natural process of growth and development, and both the child and therapist should have positive feelings about the occurrence. Stages of Therapy The process of therapy is often divided into four distinct phases -- intake, a beginning phase, middle or processing phase, and consolidation or termination phase. However, the work of the various phases is often woven into the session and is carried out throughout the entire therapeutic process. Intake Phase In most cases, a child is brought to therapy for two basic reasons:
The intake assessment determines the child's need for therapy. This determination is based on the symptoms generated by the abuse and the conditions that were part of the abuse. The intake assessment involves learning as much as possible about the presenting problem as well as the child's symptoms and their severity. Symptoms are changes in the child's usual demeanor and behavior. These changes can be subtle or dramatic. The immediate symptoms that the abuse generates are often manifested behaviorally. They may be similar to symptoms in the DSMIIIR for PTSD, anxiety disorders, depression, or conduct disorders. A child's attitudes about him/herself or about the people in his/her life may change. These deeper esteem and belief-related symptoms can affect character formation and generate long-term and lasting effects.147 These symptoms, or changes in behavior or attitudes, are communicating to the world that there is a problem and that the child needs help. Determining the Child's Need for Treatment Not every child needs therapy; therefore, it is important to determine the child's intake stage. A range of factors may need for treatment during the offset the fear following an abusive incident and child's confusion, anger, and allow the lifestyle with little repercussions from the child to resume a regular abuse. These include the following:
If the parents are concerned about the child's well-being or are having difficulty managing their own feelings about the abuse of their child, it is often useful to offer support and information that will help them cope with the disclosure of abuse. Educating the parents about how to respond appropriately to their child and identifying behaviors that might indicate the child would benefit from therapy at a later date can offset some parental fears. Taking a History Before initiating therapy, it is essential to acquire some basic information about the client, the circumstances of the maltreatment, current functioning, and the current living situation. Taking the time to discover what all the significant adults in the child's network think "happened" is a good strategy for learning about the family. A psychological evaluation can be an invaluable tool for understanding the child's social, emotional, and cognitive realms. A thorough psychological evaluation includes contact with the relevant parties who have information and insight into the child's behavior and emotional state. Specific testing can clarify emotional function and impairment as well as identify cognitive strengths and limitations. This type of information enables the treatment provider to tailor interventions to the child's emotional and cognitive abilities. Although this is most easily accomplished as part of a complete psychological evaluation, often therapists do not have access to the resources for such an evaluation. When a formal evaluation is not possible, it is strongly recommended that the therapist acquire extensive information during the intake process. The intake process incorporates the acquisition of significant child and family background information and assesses various aspects of this information to determine the potential impact on the delivery of therapeutic services. This may include an assessment of subtle factors that may support therapeutic efforts (e.g., family stability, parental coping skills) or basic factors (e.g., transportation, family finances). A good tool for gathering a complete family history is developing a genogram/family tree with the family. A clinician can assess specific, intergenerational information in many areas by asking appropriate questions as part of the development of the genogram. These areas include marital histories, the role of extended family, the educational norm for the family, use of drugs/alcohol, history of mental illness or criminal activity, significant losses for the family and the child, and significant relationships in the family system. The process of gathering the information also allows the clinician to identify the family historian and spokesperson. Developing a Treatment Plan After completing the assessment or intake phase, the clinician should prepare a plan that outlines the goals and objectives of treatment and lists the methods that will be used to address the symptoms of abuse or neglect. The estimated time for achieving the objectives should be noted. Whenever possible, the child and parents/caretakers should participate in the development of the treatment plan. Participating in the plan's development helps the child and parents feel part of the therapeutic process. Often, children and parents are more willing to participate for the length of time necessary to complete the treatment plan when they have had a part in clarifying the symptoms and learning about the tasks necessary to address those symptoms. The treatment plan should be reviewed periodically and modified when necessary. Again, this process should be undertaken with the help of the child and parents. The major goal of therapy is to address the symptoms generated by the abuse. The goals and objectives of therapy need to be concrete, practical, and realistic. Expected changes in behavior should be quantified so that progress can be monitored in objective, observable terms. Therapists must make the presenting problem understandable to the child and family. Placing the symptoms in a context removes the negative assumptions attached to behavior that seems out of control and arbitrary. Addressing the conditions that contributed to the abused or neglected child's vulnerability to victimization is another important goal of treatment. An additional goal is to enhance the child's strengths and abilities that will enable him/her to accomplish developmental tasks. Determining the Prognosis Therapists determine the treatment prognosis or outcome by the parent's, family's, and child's ability to use therapy. Parental factors that affect the child's progress in therapy include the following:
Family factors that affect the child's progress in therapy include the following:
Child factors that affect the progress in therapy include the following:
Some factors may interfere with the parents' and child's ability to benefit from treatment and may contribute to further victimization. It is important to address the following factors at intake or early in treatment so they do not interfere with the therapeutic process:
At the initial intake, as in all stages of therapy, it is important that the therapist create a strong alliance or connection with the parent or caretaker. Parents need to understand that they are very important to the child and that their support and behavior will often determine how a child utilizes therapy. The parents' cooperation will give the child permission to trust the therapist and disclose and discuss difficult information about him/herself, the family, and the abuse. The therapist must convince the parents that their input is needed and valuable and that therapy is most beneficial when parents share their ideas and concerns as well as support and participate in the experience. The child also needs to know that his/her needs will be addressed in the treatment plan. It is important the child understand that the goal of therapy is to help him/her understand what has happened and he/she was affected by the experience. The child also needs to understand that the goal of therapy is not to "change" him/her so that the parents are happy. Gil notes three tasks that must be accomplished by the end of the initial interview: 148
Beginning Phase The beginning phase of therapy focuses on establishing trust and rapport, determining the child's current level of functioning and coping style, and making therapy useful to the child. As was discussed in the first section of this chapter, establishing rapport and trust are the first steps in developing a therapeutic alliance. The therapist needs to establish a relationship with the child based on the child's interests and needs. In this way, the therapy is child-centered and determined by the child's interest, capacity, and willingness to participate. However, therapy cannot be child-driven. The child must be guided into understanding and awareness; he/she benefits from a clear plan and appropriate interventions. Being able to show how therapy can be useful in all realms of life facilitates the child's willingness to utilize the various therapeutic tasks. As stated previously, it is important to be able to communicate with children of all ages. Understanding the number of words and ideas that a child can tolerate and respond to assists the therapist to plan his/her educational and therapeutic interventions. Repeating key phrases and connecting thoughts and feelings with symbolic representation helps the child incorporate the therapeutic experience on all levels. Metaphors based on a child's interests and stage of development help the child relate to his/her experience with perspective and objectivity.150 151 It is also helpful if the therapist is familiar with the music, movies, and activities that interest various age groups. Information about important subjects such as television shows, action figures, sports, cars, and clothing styles helps to establish rapport and offers a medium by which to communicate values, behavior, and the future. Middle Phase In the middle or processing phase of therapy, there are two major tasks that the therapist helps the child accomplish – identifying how the child has been affected by the abuse and identifying ways to cope productively with his/her symptoms. In carrying out these tasks it is important for the therapist to prepare the child for "reliving" or "reexperiencing" the abuse and the feelings which may arise as a result of the abuse or neglect. Those struggling to recover from the trauma of abuse attempt to resolve four fundamental questions:
Even a child who exhibits no current symptoms of the abusive experience benefits from help in answering these questions. Facilitating resolution of the abuse includes clarifying insights, correcting distortions, placing responsibility for the abuse more objectively, acknowledging attempts to manage the abuse experience(s), and supporting positive and productive behavior. In order to accomplish this objective, the therapist needs to help the child access the memories of abuse or neglect; identify the sensations, thoughts, feelings, and beliefs that were generated by the abuse or neglect; and develop productive responses and behavior that enhances a positive self-image. Accessing the Abuse Memories Discussing the details of the abuse helps the child think about his/her experience. As the child articulates his/her unexpressed feelings and hidden thoughts, the child shares his/her personal experience of the abuse. Discussing details of the abuse can help children dispel some of the myths that were created about disclosure such as, "No one will believe you," or "People will laugh and think it's your fault." Talking about the abuse diminishes the intensity of the memories and allows the therapist to join with the child in understanding his/her experience. Sensations Physical and/or sexual abuse assaults the body with stimuli and creates sensations that can be fearful, painful, or overwhelming. Abuse arouses all the senses – sight, sound, touch, smell, and taste. These sensory memories are stored and may become stimuli for flashbacks, nightmares, phobic behavior, or panic attacks. Various factors such as lighting, location, temperature, presence of other people during the abuse, as well as physical sensations need to be noted. Pleasurable sensations (sexual abuse) can be overwhelming for the child and can become frightening, especially when the child understands that the occurring behavior is wrong. These stimuli need to identified, assessed, and explained to the child so that he/she understands that his/her reactions are often related to actual experience. Thoughts and Feelings The ability to think about the harmful experience and recognize feelings and behavior generated by those thoughts allows children to make distinctions, decisions, and choices. Thinking about their experience means gathering information that explains why the abuse occurred. It means comparing information and assessing the accuracy of that information. Thinking about the experience, discriminating between feeling safe or unsafe and recognizing abusive behavior enables the child to identify problematic situations and make choices that can help him/her remain safe from harm. As the child recognizes that he/she has the ability to think and choose, he/she begins to feel better about him/herself and feel more powerful and in control. Discharging feelings generated by the abuse is an important component of the treatment process. Identifying, acknowledging, and sharing feelings about the experience can help the child recognize the relationship between feelings and self-esteem, self-worth, and behavior. A child benefits from therapeutic experiences that allow him/her to act out his/her feelings, exaggerating his/her responses until those responses are intense enough that the child feels they represent how he/she felt at the time of the abuse. Techniques, such as hitting a pillow or punching bag, using batakas or encounter bats, or writing down all their feelings and throwing them in the wastebasket can help the child discharge some of his/her pent up emotions and begin to let go of those emotions. It is also important to teach the child socially acceptable means of expressing him/herself. These methods include direct communication, assertiveness, and negotiation. A child needs to know that hitting something, such as a pillow, may be an acceptable release for his/her feelings. However, hitting someone, such as a child or parent, is not an acceptable outlet. Haaken and Schlaps note that the patient is not simply a vessel that has been filled up with bad experiences, and consequently, can be emptied out and refilled with remedial messages.152 These researchers emphasize that the manner in which the therapist listens and reacts to the child in the process is more central to sustained therapeutic change than only abreacting traumatic experiences and reassurances. Often, a child has heard that he/she was supposed to say "no" or "run away" or "tell someone." The child may feel guilty that he/she did not do those things. The child may also feel inadequate. A child needs to realize that feeling "scared" or "angry" or "confused" may have inhibited his/her ability to respond. If the perpetrator used threats or violence, the decisions a child made at the time of the abuse may have been critical to his/her physical or emotional survival. A child may benefit from exploring the choices he/she made during the abuse incidents and may need to determine that he/she made the best choices possible given the nature of the situation. A child may also need to acknowledge that the behavior necessary during the abusive incidents or before disclosure may no longer be useful to him/her.153 Beliefs When a child is overwhelmed by sensory stimuli, he/she attempts to make sense of or find order and meaning for the experience. For a young child, or a child whose understanding is limited by his/her cognitive and emotional experience, these explanations are often primitive or inaccurate. However, these explanations or attributions are still important to identify. Attribution theory suggests that, when negative events occur, blaming oneself for the event (internalizing responsibility) results in depressed feelings whereas blaming others (externalizing responsibility) results in anger.154 When a child believes that the cause of the abuse was something to do with him/her, rather than something to do with the perpetrator, the child blames him/herself for the abuse. A child who internalizes the cause of the abuse and believes the abuse was his/her fault has a difficult time feeling good about him/herself. The child experiences the abuse as a loss of self-esteem. Simply telling the child "It wasn't your fault" is not useful and may distance the youngster ("You don't really know"). The child must come to that conclusion on his/her own. A child who externalizes the cause of the abuse, who thinks that the abuse occurred because of something about the perpetrator or the people who did not protect the child, does not have the same sense that something is "wrong" with him/her. However, this child may feel angry and experience a sense of emptiness and wonder about his/her worth and value. A child who feels that the abuse has changed his/her value may also think the abuse has changed his/her prospects and opportunities for the future. This child may feel hopeless and discouraged. A child who thinks that the abuse has marred him/her or made him/her different from other children feels differently about him/herself and his/her body. The child often projects these thoughts and feelings onto other people. By clarifying and challenging the accuracy of the child's beliefs about the cause of the abuse and exploring the significance, that is, the meaning that the abuse held for the child or the beliefs that the child has about how the abuse has affected or changed him/her, the therapist helps the child move beyond the role of victim. An abused and neglected child needs to examine his/her beliefs in light of a new perspective – he/she was not responsible for the abuse. Beliefs have a major impact on a child's behavior. A change in beliefs about the self can generate changes in behavior, which in cyclical fashion, reinforce new more positive, beliefs about oneself and others. These more positive and productive beliefs or expectations about the self, other, and the world are a self-confirming prophecy. What one expects and believes to be true is often what one recognizes and also determines how one responds. As a child begins to evaluate his/her beliefs about him/herself and begins to think of his/her reactions to the abuse or neglect in more sympathetic and favorable terms, the child often feels more hopeful and is more willing to try to make changes in his/her behavior. This, in turn, confirms a more positive sense of self and elicits more positive responses from other people. Termination Phase The consolidation or termination stage of therapy addresses integration or utilization of the abused child's new thoughts, feelings, and perceptions about him/herself as well as the new skills and behaviors that he/she has developed over time. At this point, the child has experienced most of the acute pain and grief generated by the abuse. The child is beginning to experiment with new ideas, feelings, and behaviors. In this final phase of therapy, it is important to identify the child's concerns and encourage him/her to take risks. In many ways, the outcome is less important than the attempt. Gil notes that the therapist should encourage his/her clients to take controlled risks in the following areas:155
Often, the consolidation and termination phase is a time when a child replays his/her ambivalence about attachment, dependency, and autonomy. The child may vacillate between wanting therapy to "get over with" and feeling fearful that he/she will not be able to manage without his/her therapist. The child benefits from hearing that change is often difficult, and saying goodbye to a therapist can feel somewhat like saying goodbye to a parent. The child also benefits from hearing that terminating a therapeutic relationship is a kind of loss that happens when he/she is ready to move on to another phase in his/her life. Sometimes, a child terminates his/her therapeutic relationship before he/she has integrated new thoughts, feelings, and skills that will increase his/her esteem, safety, and affiliation. In these cases, it is helpful to have an "open door" policy. The child is encouraged to contact the therapist if he/she needs help, wants to schedule a followup appointment, or continue therapy. Long-Term Issues The therapist also needs to be aware of possible long-range issues for maltreated children, so he/she can help him/her recognize when additional therapy may be indicated. These long-term issues include developmental milestones, such as puberty, when sexuality and relationship issues begin to be dominant themes for children; marriage with issues of trust, affiliation, and intimacy; and pregnancy and childbirth, which often trigger concerns about protection and safety for the young child, issues of loss and grief, and questions about parenting. The following factors can have an impact on the length of time necessary for resolution of the experience of child abuse and neglect:
Treatment Modalities The following modalities are effective in helping children and their parents learn about the effects of abuse and neglect. A thorough assessment enables the clinician to determine which method will best meet the child's needs. Sometimes children participate in more than one modality, either in incremental steps or concurrently. For example, some children benefit from concurrent individual and group therapy. They have the opportunity to work on interpersonal skills in individual therapy and reap the rewards of appropriate interaction during group. Psychoeducational groups that present information about the causes and effects of abuse and neglect and offer the opportunity to explore one's experience can be an effective means of educating parents and introducing topics for them to explore in individual or group therapy. Primary Prevention Programs The purpose of primary prevention programs for children is to help the child become knowledgeable about his/her rights to safety and protection. Because children are known to be more seriously affected by prolonged abuse, knowing what abuse is and encouraging disclosure early in the abuse experience is a prevention goal well worth the effort.156 In many communities, prevention programs are initiated in preschool and day care settings and in elementary school. Prevention programs give the child permission to talk about abuse and neglect and help the child understand what to do if abuse is occurring in his/her life. There is reason to believe that, in many situations, a child is not able to behave in the way that prevention programs recommend, (e.g., "Say no, run, and tell").157 However, offenders report that a (child's) threat to tell someone would have the greatest impact on deterring abuse. This message to children may be among the most important that safety education programs can deliver.158 Play Therapy Play therapy is an effective modality that helps the child express feelings, act out behaviors, and gain mastery and control over memories and feelings generated by the abusive or neglectful experience. A child uses play to manage his/her fears and anxieties about the abuse, express his/her feelings about what happened to him/her, and demonstrate their knowledge and understanding about relationships. Play therapy allows the child to represent symbolically those events that generate fear and anxiety and helps the child move toward resolution and integration of the frightening experience. Play therapy is especially effective with children who do not have the verbal or cognitive skills necessary to participate in a more direct approach to discussing their feelings. A child who is developmentally or emotionally unable to express him/herself verbally can benefit from an experience that allows him/her to demonstrate his/her feelings, fears, and attempts at mastery. Themes that are repeated during play therapy should be studied. Interventions need to be developed to help the child gain a sense of mastery and control over an overwhelming experience. It is incumbent upon the therapist to interpret this play material in a manner that adds insight and meaning to the child's experience and facilitates resolution or closure of the traumatic event. Individual Therapy Usually, individual therapy is the child's first introduction to treatment. It is an opportunity for the child to interact with a supportive and knowledgeable adult and develop a relationship that models appropriate adultchild relationships. Individual therapy also allows the therapist time to assess and evaluate the child's interpersonal skills and help the child learn age-appropriate and engaging behaviors to interact with peers. The goal of individual therapy is understanding, integration, and resolution of those experiences that affect development, interaction, and safety. Individual therapy is most beneficial in helping children address developmental issues of trust, mastery and control, and identity. Individual therapy generally is helpful in supporting disclosure of abuse and neglect, helping the child identify issues related to their experience, and in resolving intrapersonal issues. A child who will testify during a criminal proceeding can benefit from individual therapy. It can help the child address his/her fear and anxiety related to confronting the perpetrator and testifying in front of strangers. Most children are also less likely to be affected by or incorporate other victims' circumstances than are children who have participated in group therapy before having to testify. Group Therapy Group therapy is especially helpful for decreasing isolation, improving social skills, and monitoring and intervening in problematic interactional patterns of behavior. Group therapy also allows the child to identify and learn from peers and group leaders and helps the child learn new and possibly more effective ways of interacting and communicating about his/her circumstances. Group therapy can facilitate participation with a supportive and understanding peer group and allow the child to practice many of the skills that will improve his/her ability to affiliate and evaluate relationships. Additional benefits provided by group therapy include normalization of the experience by hearing similarities in victims' feelings and responses to abuse or neglect, corrective capitulation of the primary family group, development of socializing techniques, acquisition of the sense of belonging, and catharsis.159 Group therapy is not warranted for a child who is unable to manage his/her impulsive behavior. This child would be disruptive in group or unable to gain acceptance. A child with limited social skills often needs individual therapy to prepare him/her for the social experience of group therapy. Family Therapy Family therapy is most helpful when the family is willing and able to view the abuse or neglect as an issue that needs to be addressed by all the members in the family. Family therapy is an opportunity to explore roles and relationships, help family members recognize the impact that their behavior has on each other, and increase family cohesion and belonging. Family therapy can facilitate problem solving and improve communication between members. Family therapy seems most helpful after the individual family members have addressed their intrapersonal and developmental issues in individual or group therapy. Family therapy is often an effective tool to help family members address feelings related to reunification (when the child or offending parent has been removed from the family) and develop new behaviors that help each family member feel capable of contributing and benefiting from living together. Family therapy is not warranted when adults, especially if they are perpetrators of abuse, are unwilling to take responsibility for their behavior. Issues of blame, anger, and violence can be addressed in a family therapy format, but each individual participant must feel safe and capable of eliciting protection, if necessary. Summary Therapy is one of many important strategies to help abused and neglected children move beyond the role of victim and continue their progress toward positive and productive adulthood. Therapy with abused and neglected children is often demanding and challenging. However, it offers the immediate reward to the therapist of knowing that he/she is making every effort to help the child and the family who are struggling to overcome the effects of abuse and neglect. For this reason, therapy is a valuable service and a major contributor to the well-being of maltreated children and their families.
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