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Treatment Of Child Sexual Abuse
Treatment of child sexual abuse is a complex process. Orchestration of treatment in the child's best interest is a genuine challenge. Moreover, it is often difficult to know how to proceed because there are so few outcome studies of treatment effectiveness.
In this chapter, case management issues are discussed; a model for understanding why adults sexually abuse children is proposed; treatment modalities are described; and treatment issues are examined. The focus of the discussion is primarily on intrafamilial abuse.
Case Management Considerations
One of the reasons sexual abuse treatment is such a challenge is that it occurs in a larger context of intervention. Therefore, coordination is of utmost importance and ideally is provided by a multidisciplinary team. Treatment issues are then handled by the team as part of overall intervention.
The team usually consists of the various professionals directly involved in the case and their consultants and, as noted earlier, begins its activity at the time of case investigation. The composition and functioning of teams vary by locality, and the level of participation of team members often varies depending on the stage of the intervention. In an intrafamilial case, the members active at the treatment stage will ordinarily include the Child Protective Services (CPS) and/or foster care workers, the therapists treating various family members, professionals providing other services (e.g., homemaker, parenting guidance), a representative from the prosecutor's office, and relevant consultants. The frequency of meetings will depend on the needs of the case and how the team is structured.
The following issues are the most important of those the team should consider at this stage of intervention: separation of the child and/or the offender from the family, the role of the juvenile court, the role of the criminal court, the treatment plan for the family, visitation, and family reunification.
Case management decisions are often provisional; that is, they are based on what information about the family members and their functioning is available when decisions are made. Treatment is often a diagnostic process. The positive or negative responses of family members to treatment determine future case decisions. Outcomes of court proceedings can impinge upon and alter case management decisions and treatment.
The team meets periodically to assess progress and make future plans. Because of the complexity of case management decisions and the fact that a decision in one realm can have an impact on other aspects of the case, especially on treatment progress and outcome, multidisciplinary decision making is crucial. In the absence of a multidisciplinary team, such decisions should be made in consultation with other relevant professionals.
Before the implementation of the treatment plan, the following case management decisions should be addressed:
- Should the child remain a part of the family?
- Do the courts have a role in the case?
- Is there a question of visitation?
Guidelines for making these decisions will be discussed.
Should the Child Live With the Family?
The preferred outcome in cases of sexual abuse, as in other types of child maltreatment, is that after intervention the family will be intact.
Generally at the time of disclosure of the sexual abuse, the offender is not separated from the family. The victim may be removed if the mother is unable or unwilling to protect and support the victim or if the victim wishes to be removed. Many professionals advocate the removal of the offender even in circumstances in which the victim is removed.
After these initial decisions, a longer term plan must be made about whether the child should be a part of the family and, if so, whether or not that family should include both parents. This plan will be based on an assessment of each parent.
Aspects of the functioning of both parents outlined previously in the discussion of risk assessment should be examined in deciding about the child's future living situation. These include the following factors for the offender:
- the extent of the offender's sexually abusive behavior;
- the degree to which the offender takes responsibility for the sexual abuse;
- the number and severity of the offender's other problems, for example;
- substance abuse,
- violent behavior,
- mental illness, and
- mental retardation.
Regarding the nonoffending parent, the following factors should be assessed:
- reaction to knowledge about the sexual abuse,
- quality of relationship with the victim,
- level of dependency on the offender, and
- the number and severity of other problems.
Other possible problems are similar for the nonoffending parent and the offender.
Although these factors are universally useful to consider, in specific cases other factors may be important or even overriding.
Offenders who have engaged in a small number of sexual acts, have taken responsibility for their behavior, and have few other problems are judged to have positive findings in these key areas and are usually treatable. Negative findings in these three areas mean that the prognosis for positive treatment outcome is quite guarded. When mothers are protective of victims when they discover the sexual abuse, have good relationships with victims, are not unduly dependent on the offender, and do not have other significant problems, their treatment prognosis is positive. Again negative findings mean that the treatment prognosis is poor.
These proposed variations in parental functioning suggest four possible combinations: both parents may have positive findings, indicating a good treatment prognosis (case type 1); the nonoffending parent may have positive findings, and the offender negative ones (case type 2); the offender may have positive findings and the nonoffending parent negative ones (case type 3); and finally, both parents may have negative findings (case type 4).110
Different combinations argue for different intervention plans and long-term goals. General strategies are suggested in the decision matrix in Chart 3.
This matrix suggests how professionals hope to be able to make decisions. However, the parents are usually more complex than the matrix suggests. Probably in the majority of cases, the parents present a mixed picture, rather than appearing to have either a very good or bad prognosis. Moreover, as already suggested, there may be gaps in information about the family when treatment planning is undertaken and parental functioning is not static. Progress or lack of progress in treatment may result in reconsideration of the initial placement and treatment plan. Because of these complexities, most sexually abusive families should and do receive a trial of treatment. This generally entails individual treatment for all parties and the appropriate use of groups. Initial case decisions are periodically evaluated based on treatment outcome and reassessed accordingly. In addition to being useful in placement and treatment planning decisions, the matrix may offer guidance in terms of court intervention. Most professionals would agree that the Juvenile Court should be involved in all four types of cases, perhaps with the exception of a small number of those falling into case type 1. These might be cases in which the offender confesses to his wife or family, the family seeks treatment, and the abuse is then reported to CPS by their therapist.
There is also increasing consensus that criminal charges should be filed, even though the offender appears treatable. Some professionals feel that even treatable offenders should do some jail time, while others see the criminal process as a means of ensuring that the treatable offender will take responsibility for his behavior and/or enter into treatment. However, criminal prosecution is especially important in cases categorized as case types 2 and 4 to offer some protection to both the family and society from the offender.
In addition, factors related to the child should also be considered. These include the child's wishes. To be more precise, if the child does not wish for a reunified family, that desire should be given a great deal of weight. A child's wish for the offender not to leave the home, however, should generally not be granted. In addition, some sexually abused children are so damaged, because of the abuse and other conditions, that they require specialized care outside the home.
The same assumption is made here as in earlier chapters, that there is a single offender, usually a father figure, and a nonoffending parent, usually a mother figure. If that is not the case, and there is more than one offender, especially within the family, prognosis is much poorer. Even more problematic are cases in which both parents are offenders; in such instances, family reunification is extremely unlikely to be in the child's best interest.
The Role of the Courts
Two or three courts are potentially involved in a sexual abuse case—the Juvenile Court, responsible for child protection; the Criminal Court, responsible for offender prosecution; and the Divorce Court, if either parent decides to pursue divorce.
Court involvement can be either a help or a hindrance to therapeutic goals. The challenge is to integrate court involvement into the overall intervention. Early decisions about the role of the court can facilitate its role in the therapeutic process.
The court can be helpful in compelling family members, especially offenders, into treatment; in protecting victims and families from offenders; and in effecting alternative living situations for offenders (or victims, if necessary).
Court involvement can be problematic because legal safeguards for the defendant may prevent certain evidence from being admitted; because the adversarial process may interfere with the therapeutic process, including disruption of offender treatment by incarceration; and because it allows procedural delays that may prevent timely intervention.
Finally, testifying in court may have a positive or negative effect on the child. The effect, in part, depends on its outcome. That is, if the case is won, the impact of court testimony is more likely to be positive.
Victims may gain a sense of mastery over the sexual abuse from testifying. If they are believed, they may derive a degree of vindication when they see that the offender has to pay for what he did. Completing the court process may also engender a sense of closure for the victim.
On the other hand, victims may experience court testimony as additional trauma. Some are required to confront their abusers, endure lengthy cross-examination, and reveal shameful experiences to an audience. If possible, the courtroom should be cleared during the child's appearance. Testifying in court, which rarely entails a single appearance, may enhance the child's perception of him/herself as a victim, rather than a normal child. Moreover, because the court process tends to be protracted, it may delay resolution of the victim's treatment issues. For more detailed information on the role of the court in child abuse and neglect cases, the reader is referred to another manual in this series entitled Working With the Courts in Child Protection.
As noted previously, in most cases it is appropriate for the offender to leave the home and for the victim to remain. In other cases, the victim should be removed to protect her/him from further sexual abuse and/or emotional abuse. (In a very small number of cases, it will be appropriate to leave the family intact after disclosure.) Obviously what constitutes visitation will vary depending on the living arrangements.
However, there are some guidelines to be used by the court and the professionals in making decisions about visitation. Many professionals recommend no contact between the victim and the offender, if the child is to appear in court, until after her/his testimony. If the mother and/or other family members are unsupportive of her/his testifying, they may be prohibited from seeing her/him until after her/his testimony.
If the child genuinely does not wish visitation, there should be none. There should be no unsupervised visitation until the child feels she/he will be safe and the offender has been assessed and found not at risk to reoffend. In some cases, the child may want visitation or unsupervised visitation when it is not deemed in her/his interest by the professionals. In such a circumstance, professional opinion should prevail.
Assuming all parties want visitation, as the offender (and other family members) make progress in treatment, visitation is initiated and becomes progressively more liberal (i.e., more frequent, for longer time periods, and with less supervision). As successive steps are taken to make visitation more liberal, it is important to make sure the victim (and her/his caretaker) want this change. The multidisciplinary team or the child's therapist needs to make these decisions.
Causal Models of Sexual Abuse
Before developing a treatment plan, it is important to have an understanding of why the sexual abuse occurs, both generally and in the particular case under consideration.
It is useful to briefly examine the history of causal theories of sexual abuse before a discussion of the current level of professional understanding. Historically there have been two rather separate efforts to understand the phenomenon of sexual abuse, its causes, and its resolution. These can be conceptualized as the family-focused perspective and the offender-focused perspective.
The Family-Focused Perspective
Those taking a family perspective focused their attention on incest and developed hypotheses that family dynamics are at the root of sexual abuse. Specifically, clinicians taking this perspective described the collusive mother, who has estranged herself from the father, as the "cornerstone" of the incestuous triad and the victim as a parental child who has replaced her mother as sexual partner to the father.111
The implications of this model in terms of treatment are that the mother and the daughter must change, but the offender is not necessarily required to take responsibility for his behavior and develop strategies to control it. Most professionals working in the sexual abuse field recognize the limitations of a perspective that focuses purely on family dynamics.
This perspective does not help very much in explaining extrafamilial sexual victimization and, taken to its extreme, represents the offender as the hapless victim of family dynamics. Moreover, recent research, which finds that a substantial proportion of incest offenders begin their sexual victimization as adolescents and experience arousal to children before they become fathers, calls into question assumptions about the pivotal role of family dynamics in incest.112
The Offender-Focused Perspective
Those who work primarily with perpetrators have historically been located in institutions for adjudicated offenders. Most of these clinicians/researchers appreciate that their clientele do not represent the full spectrum of sex offenders. Their focus has been on understanding the etiology of sexual abuse by examining the physiological and psychological functioning of offenders. They typically do not have access to families to understand any role they might have played in the victimization, nor its impact on the families. Moreover, as these clinicians develop and implement treatment strategies, they may have to do so in a vacuum and in an artificial environment. There are frequently both problems translating what is learned in treatment in the institution to the offender's normal environment and failure to continue needed treatment when the offender returns to the community.
An Integrated Model
Efforts to integrate the family and offender perspectives to the causes of sexual abuse began in the mid-1980's. Finkelhor examined the spectrum of clinical literature and research into the causes of sexual abuse and developed a model of causation that incorporates both the family-, and offender-focused perspectives. He posits four preconditions that must obtain for sexual abuse to occur: factors related to the offender's motivation to sexually abuse; factors predisposing the offender to overcoming internal inhibitors; factors predisposing to overcoming external inhibitors (e.g., absence of environmental obstacles); and factors predisposing to overcoming child's resistance (e.g., a vulnerable child or the use of coercion). Finkelhor applied this model on both the individual (case) level and the sociocultural level.113 114
The model presented here is somewhat different and more practice-focused. It proposes that there are some causal factors that are prerequisites for sexual abuse and there are others that play a contributing role. Prerequisite factors sexual arousal to children and a propensity to act on arousal are to be found within the offender, whereas contributing factors may come from the culture, from the family system (including the marital relationship), from his current life situation, from his personality, or from his past life experience.
The presence of the two prerequisite factors (sexual arousal to children and propensity to act on arousal) is both necessary and sufficient to result in sexual abuse. This is not the case for the contributing factors. For example, a man does not sexually abuse his daughter because his marriage is unhappy. More than half of American marriages end in divorce, suggesting that a substantial number of marriages are unhappy. But only a very small number of men in unhappy marriages sexually abuse their children.115 116
Contributing factors may enhance the prerequisite factors or they may, independent of an effect on the prerequisites, increase risk. An example of the former dynamics is found in the role of alcohol abuse. It usually leads to diminished capacity to control behavior, which may increase the propensity to act on sexual arousal to children. (Chemicals are also used by some offenders to cope with guilt related to their abuse behavior.) An example of the latter dynamic is that found in situations of unsupervised access to children. It may enhance risk because it provides opportunity for an offender who is aroused to children and prone to act on that arousal. This model will be referred to again in the discussion of treatment issues.
In this section, the role of various treatment modalities is described. An approach to treatment that addresses prerequisite and contributing causes of sexual abuse and meets the treatment needs of victim, family, and offender must be multimodal. Ideally, individual, dyadic, family, and group treatment modalities should be available, especially if reintegration of the offender and/or the victim into the family is planned. However, therapists and programs without this full spectrum of services can be successful in treatment.
Although group, individual, dyadic, and family modalities should be available, it does not appear to be necessary to have a rigid progression from individual to dyadic to family therapy. However, it is crucial that progress be made in individual and sometimes dyadic therapy before family therapy is indicated and before individuals can benefit from it. The types of treatment and their uses will be discussed as follows:
- Group therapy is generally regarded as the treatment of choice for sexual abuse. However, usually groups are offered concurrent with other treatment modalities, and some clients may need individual treatment before they are ready for group therapy. Furthermore, there will be a few clients who are either too disturbed or too disruptive to be in group treatment.
- Groups are appropriate for victims, siblings of victims, mothers of victims, offenders, and adult survivors of sexual abuse. In addition, "generic" groups that include offenders, parents of victims, and survivors of sexual abuse have been found to be very powerful and effective for all parties involved.
- Groups may be time-limited, long-term, or open-ended. They may deal with specific issues (e.g., relapse prevention, sex education, or protection from future sexual abuse), or they may deal with a range of issues. Some programs have "orientation" groups for new clients, usually with separate groups for children and adults.
- Victim's and offender's groups have been brought together for occasional sessions. Models that have concurrent groups for victims or children and their nonoffending parents, where from time to time the two groups join for activities, are very productive.
- Individual treatment is appropriate for victim, offender, and mother of victim (as well as for siblings of victims and survivors). As a rule, an initial function and a major one for individual treatment is alliance building. All parties have to learn to trust the therapist and come to believe that change is possible and desirable. The members of this triad may have different levels of commitment to therapy, with the victim usually the most invested and the offender the least.
- Dyadic treatment is used to enhance and/or repair damage to the mother-daughter relationship, the husband-wife relationship, and the father-daughter relationship, as well as to deal with issues initially addressed in individual treatment.
- Family therapy is the culmination of the treatment process and is usually not undertaken until there has been a determination that reunification is in the victim's best interest.
- Multiple therapists can be very helpful. Such a complex series of interventions can rarely be provided by one individual. If possible, two therapists should be involved, even if it is only one person doing the group work and another the individual, dyadic, and family work. However, because each family member will typically participate in a group as well as other treatment modalities, there are usually several clinicians involved with a single family. Moreover, there are reasons other than logistics for involving several clinicians.
- Sexually abusive families are very difficult to work with, and therapists need one another's support. Such families are crisis-ridden and multiproblem, making it very difficult for one person to have total responsibility for the family.
- Assigning a different therapist to the victim and to the offender "recreates," although artificially, a family boundary that was crossed when the sexual abuse occurred. It also enhances a sense of privacy and safety for the victim—two elements violated by the offender.
- In addition, cotherapy, using both a male and female therapist, has considerable therapeutic advantage. It exposes family members to appropriate role models of both sexes. Cotherapy also enhances the ability of clinicians to effect change because of the leverage it allows, particularly in group therapy.
- Finally, decisions that must be made in the course of treatment are very difficult ones, and mistakes are potentially devastating. Two or more heads may be better than one. And as noted earlier, ideally clinicians should be guided in their decisions by the input of a multidisciplinary team.
There are two main objectives in sexual abuse treatment:
- dealing with the effects of sexual abuse, and
- decreasing risk for future sexual abuse.
Victim treatment tends to focus more on the former; mother's treatment issues are fairly evenly split; and the offender's issues are predominantly in the realm of preventing future victimizing behavior, although the initial stage of treatment may focus on the effects of the abuse disclosure on him/her.
Treatment Issues for the Victim
The saliency of treatment issues discussed in this section will vary for each victim, some possibly being irrelevant. Also, there may be additional treatment issues for victims that are not discussed here. The following issues appear to be the most important:
- trust, including patterns in relationships;
- emotional reactions to sexual abuse;
- behavioral reactions to sexual abuse;
- cognitive reactions to sexual abuse; and
- protection from future victimization.
These issues are interrelated. As the following discussion illustrates, the categorization is somewhat artificial.
Being a victim of sexual abuse can have a devastating effect on children's object relations, particularly the ability to trust other people. In intrafamilial sexual abuse, the impact may be pervasive because a caretaker, who should be a protector and a limit-setter, exploits the child and violates the boundaries of acceptable behavior. Furthermore, this damage may be exacerbated by an unsupportive nonoffending parent. Moreover, sexual abuse may not be the only way in which the child's trust is undermined. The victim may experience other maltreatment or traumatic experiences in the family.
However, children sexually molested outside the home may also experience problems with trust. This may come about because the person who victimizes the child is someone to whom the child has been entrusted by the parents, as happens, for example, when the abuser is a child care provider. These victims frequently perceive their parents as having given permission for the exploitation. Alternatively, the offender may be a person in a position of authority over the child and she/he feels compelled to comply. Then children may have considerable difficulty trusting persons in positions of authority in the future.
The challenge to the therapist is to create circumstances in which the child has positive experiences with trustworthy adults in order to ameliorate the damage to the child's ability to trust. This may involve rehabilitating the parents and/or creating opportunities for appropriate relationships with adults, for example, with foster parents, mentors, or other relatives. An admonition to therapists is that they must be honest and dependable in order to create an atmosphere of trust.
Emotional Reactions to Sexual Abuse
Three common emotional consequences of sexual victimization are a sense of somehow being responsible and therefore feeling guilty, an altered sense of self and self-esteem because of involvement in sexual abuse, and fears and anxiety.
- Feeling responsible. An offender may make the victim feel responsible for the sexual abuse, for the offender's well-being, and/or for the consequences of disclosure. Victims may also feel guilty for not having stopped the sexual abuse as well as for any positive aspects of the abuse, such as physical pleasure, the special attention given by the offender, or an opportunity to have control over other family members because of "the secret."
The role of the clinician is to help the child understand intellectually and accept emotionally that the child was not responsible. The adult sexually abused the child; the child did not sexually abuse the adult. It was the adult's job not the child's to stop or prevent the abuse.
- Altered sense of self. Guilt feelings as well as the invasive and intrusive nature of the sexual activity impact negatively on the child's sense of self and self-esteem. As Sgroi puts it, victims suffer from "damaged goods" syndrome.117 The effect is both physical, in that children have an altered sense of their bodies, and psychological, in that children may see themselves as markedly different from their peers.
The task of the therapist is to make victims feel whole and good about themselves again. Work, mentioned above, that addresses the issue of self-blame is helpful. However, so are interventions that help children view themselves as more than merely victims of sexual abuse. Normalizing and ego-enhancing activities, such as doing well in school, participating in sports, getting involved in scouts, or helping a younger victim, can be very important in victim recovery.
- Anxiety and fear to be discussed here are related to the traumatic impact of the abuse per se on the child rather than environmental responses to it. The victim develops phobic reactions to the event, the offender, and to other aspects of the abuse. Experiences that evoke recollections of the abuse come to elicit anxiety. In some children this anxiety and phobias become pervasive and crippling because of the level of avoidance they engage in to reduce their stress.
Before treating the child's fears and anxiety, the therapist must be sure the child is not being sexually abused or at risk for sexual abuse. Then the therapist engages the victim in a series of interventions that allow her/him to gradually deal with the abuse and related phobias and anxiety in ways that usually avoid excessive stress and allow mastery.118 These may include discussions, play therapy, or interventions in the child's environment. For example, the victim may be encouraged to ventilate by talking about the abuse and accompanying feelings, thereby reducing the level of distress related to it. Similarly, a child who is phobic about being left with a babysitter may be left with a relative first for short and then longer time periods, then with a babysitter for brief and then longer periods and thereby be desensitized to babysitting situations.
- Additional emotional reactions may be found. Depending on the circumstances of the victimization and the child's personality, she/he may react with regression, anger, depression, revulsion, or posttraumatic stress disorder to sexual abuse. These emotional reactions are likely to manifest themselves in problematic behaviors. These behaviors will be discussed in the next section.
Behavioral Reactions to Sexual Abuse
As suggested in the second chapter, behavioral effects of sexual abuse can include sexualized behavior and other behavior problems.
- Sexualized behavior. A serious reaction is sexualized behavior. Children who have been sexually victimized may masturbate excessively and openly or sexually interact with other people. Every act of sexualized behavior has the potential for increasing the probability of future acts. Not only is the activity likely to be physically pleasurable, but it may also enhance the child's view of her/himself as a sexually acting out person. Such acts may also stigmatize the child, which has a negative impact on the child's sense of self.
Clinicians should work to diminish and/or eliminate sexualized behavior through teaching behavioral controls. Sexual acting out may be controlled, for example, by teaching the child to masturbate privately. Behavior management techniques, which can involve rewarding "sex-free" days and using "time-out" for sexual acting out, can be taught to the child's caretaker. In addition, the child's energies that might have gone into sexual behavior can be channeled into more age-appropriate activities by having a caretaker monitor the child, interrupt any sexual acting out, and provide opportunities for positive alternative behaviors. These interventions are conducted with the child's caretaker and/or in dyadic work with child and caretaker.
One of the reasons treatment of sexualized behavior is so essential is because of a recently recognized phenomenon called the victim to offender cycle. Both male and female victims are at risk for this problem. Many offenders begin as victims, whose response to sexual abuse is to identify with the aggressor and to sexually act out in order to cope with their own sense of vulnerability and trauma. Professionals must recognize the potential danger of allowing sexualized behavior to go untreated, which is that the child then is at risk for becoming first an adolescent offender and eventually an adult offender. The child not only damages him/herself, but also may cause grave harm to many other children over the course of time.
- Other behavior problems. Other behavioral reactions to sexual abuse include such problems as aggression toward people and animals, running away, self-harm (cutting or burning), criminal activity, substance abuse, suicidal behavior, hyperactivity, sleep problems, eating problems, and toileting problems.
Some of these problems, for example, difficulties with sleep, eating, toileting, and being alone, may be acute after disclosure but diminish over time and eventually disappear. Short-term intervention, labeling the behavioral problems as common reactions, and helping the victim resolve the underlying emotional or cognitive issues is generally helpful. Parents are encouraged to be understanding.
Treatment strategies for all behavioral problems include helping the victim understand the relationship between the behaviors and the sexual abuse and emotional or cognitive reactions to it; helping the child develop insight into the self-destructive nature of some of these behaviors; assisting the victim in more appropriate expression of the emotions, for example, anger; and behavioral interventions to diminish and eliminate problematic behavior. With older children, group therapy is usually very useful in addressing these problems.
Cognitive Reactions to Sexual Abuse
An important part of treatment of victims of sexual abuse is to help them understand the meaning of the abuse. This includes learning what appropriate and inappropriate touching entails; what is wrong about sexual activity between adults and children, if they do not know this; why adults or a particular adult was sexual with them; and in some cases, why they were chosen as targets and what that means to them. How these issues are addressed will vary with the child's developmental stage. They may be more adequately dealt with in group treatment than individual therapy, and sometimes having the offender take full responsibility for the abuse in dyadic therapy with the victim is useful.
Moreover, an adequate explanation for a child at a young age may not be sufficient as she/he grows older. Thus, this particular issue will need to be addressed at a more sophisticated level as the child matures. This may be done by a parent but in some cases will need to be done by a therapist.
Protection From Future Victimization
Treatment of victimized children needs to include strategies for future protection. Teaching children to say no and tell someone may be useful, especially if the material is presented in a group setting and there are opportunities to role play resisting sexual advances. Specific protective strategies involving family members and helping professionals need to be developed in intrafamilial sexual abuse situations. Additionally, the therapist must appreciate that placing even partial responsibility for self-protection on the victim is potentially an overwhelming burden.
Treatment Issues for the Mother (Nonoffending Parent)
Although the discussion that follows refers specifically to mothers as nonoffending parents, much of the material is also applicable to nonoffending fathers. Treatment issues for mothers of victims can be categorized under the following four general headings.
- issues related to the sexual abuse,
- issues related to the mother-victim relationship,
- issues related to the offender (spouse), and
- other personal issues.
These issues are particularly relevant to cases involving mothers in intrafamilial sexual abuse but also can be important when other persons are the abusers. Like victim treatment issues, they are interrelated, and there may be other issues that are salient in a given case. The relationship of the mother's treatment issues to factors to be assessed in making decisions about victim reunification with the family will become apparent.
Issues Related to the Sexual Abuse
It is difficult for most people, including mothers of victims, to understand why an adult might want to be sexual with a child. This is often the first issue that the clinician must address with the mother. This may be especially difficult for the mother to understand if the offender is her spouse or another close relative.
The therapist may offer professional understanding into the general causes of sexual abuse or those specific to the case. The parent might also be given material to read. However, group involvement, in either a generic sexual abuse or mothers' group, may be the most effective method for addressing this issue.
A related issue is that of believing the victim's disclosure of sexual abuse. Many parents will try to explain it away. As noted in the discussion of assessment of the nonoffending parent, coming to believe a victim is usually a process, rather than instantaneous.
The therapist may describe what in the child's disclosure makes her/him believe the child or speak generally about the conclusion that children rarely make false allegations and the reasons for that belief. However, group treatment, in which the mother is confronted by others who have also struggled with disbelief, is often the most effective mode for dealing with this issue.
Finally, the therapist will want to help the mother understand her role in the abuse, if she has had one. The nonoffending parent is not to blame for the victimization but in some instances may have contributed to risk of abuse or prolonged abuse, for example, by leaving the child for long periods of time with the offender or by discounting the child's early disclosures.
Interestingly, a good prognosis is suggested when a mother feels very guilty and the therapist must work to alleviate her sense of responsibility. Conversely, a poorer prognosis is indicated when the mother sees herself as absolutely blameless and the therapist has to point out things that the mother might have done differently that could have prevented or minimized the abuse. As with other issues related to the abuse, this issue may be best dealt with in group therapy.
Issues Related to the Mother-Victim Relationship
Treatment of intrafamilial sexual abuse that results in successful reunification of the family rests upon the mother's relationship with the victim. This may be a very problematic relationship at the time of disclosure. The offender may have engaged in manipulations that have alienated mother and victim from one another. The victim may have developed problematic behaviors because of the abuse, which have damaged her relationship with the mother. The consequences of disclosure may be blamed on the victim, or the mother may never have related well to the victim (or other people).
This problem appears to be less severe with boy victims. Mothers are more likely to be supportive of them. In part this is because when boys are sexually abused, the offender is more often, than with girls, someone outside the family. Moreover, when victimized within the family, boys tend to be abused along with their sisters,119 meaning the mother is less likely to regard a single child as to blame or as the source of her frustrations. However, this phenomenon may also relate to differences in role relationships between mothers and daughters and mothers and sons.
The therapist tries to enhance the mother-victim relationship by assisting the mother in developing empathy for the victim; by facilitating their communication; by helping them resolve ongoing problems in their relationship, such as disputes regarding bedtime or chores; and by helping them develop opportunities for mutually enjoyable experiences. Initial work is usually done in individual treatment with the mother, and later within the mother-child dyad.
Improving the mother-child relationship is generally a prerequisite to assisting the mother in being protective of her child in the future. Although interventions are employed to help the offender control his behavior in the future, the major source of protection for the child is the mother.
Intervention to make the mother more protective is implemented in a variety of ways. If the mother has a more positive relationship with the child, she will be more predisposed to protect the child. Treatment to improve the mother-child communication should enhance the likelihood the child will tell mother. Moreover, the therapist usually works with both the child and the mother to encourage communication specifically about the child's safety.
Especially if the family has not been separated or, if separated, as the family is reunited, specific guidance should be given to the mother regarding safety. For example, she may be instructed not to leave the child alone with the offender, not to let the offender bathe the child, not to allow the offender any control over the child's activities, and/or not to give the offender the responsibility for disciplining the child. How long these protections remain in place will depend on the case.
Finally, the therapist usually helps the mother develop a specific plan in case the offender does reoffend. Her plan is communicated to the victim, the offender, and the rest of the family. It can often involve dissolving the marriage.
Issues Related to the Offender (Spouse)
In cases of intrafamilial sexual abuse, the mother must decide whether she wants to sever her relationship with the offender or try to salvage the relationship. Some mothers decide at the time of disclosure to terminate the relationship or, alternatively, to work to preserve it. For others, this decision takes time and observation of the offender's progress or lack thereof in treatment. Still others are indecisive and change their minds more than once.
The clinician may have an opinion about what the mother should do. However, it is wise to allow the mother to make her own decision. This does not preclude sharing opinions about the offender's treatability and the likelihood of the victim remaining or returning home should the mother choose to stay with an untreated or untreatable offender.
In cases in which the offender is the mother's partner, regardless of the decision to leave or to stay, the mother will need to address her relationships with men. The goal is to help her gain some insight into these relationships, including that with the offender, and to understand their problematic aspects. If she intends to stay with the offender, she must be assisted in changing that relationship. If she leaves him, the goal of insight is to help her in future relationships. Group treatment with other mothers is particularly useful in this work. Of course, if her intention is to preserve the relationship with the offender, dyadic work with the offender is necessary.
Often mothers are very dependent on the men who have abused their children. In most instances, it is important to help her become less dependent so that she will be better able to seek what is in her children's and her interest, should there be a conflict between the offender's interest and that of the rest of the family.
Independence may be fostered by involving the mother in activities outside the home, including therapy; enhancing her financial independence; encouraging her to do things without his assistance; and facilitating her assertiveness when they are in conflict. Opportunities for these types of interventions may present themselves quite naturally if the offender must leave the home at the time of disclosure of the sexual abuse. Because of the mother's need to function autonomously in his absence, he may return home to a situation quite different from the one he left.
Other Personal Issues
Most mothers must deal with other issues related to current functioning and past experiences in therapy. The most common issue regarding current functioning is low self-esteem. However, other issues, such as substance abuse, experiences of violence, dependency, and emotional problems, often need to be addressed as well.
The most common issue in terms of past trauma is having been sexually victimized themselves. Such an experience can have a variety of implications in terms of the mother's ability to deal with her children's sexual abuse. For example, at the time of disclosure, a mother may be so overwhelmed because of her own abuse that she cannot deal with her child's victimization. In such instances, her abuse may have to be addressed first. Her own victimization may have an impact on her willingness to believe the victim, her ability to discern risky situations (she may not note them), and her choices of partners, playing a role in her choosing someone who is sexual with children. In addition, it may cause her to mistakenly believe her children are being victimized.
Treatment Issues for the Father as the Offender
Although the following discussion will refer to the father as the offender, it is equally applicable to cases involving stepfathers and unmarried partners of mothers who are offenders. It is also relevant to some situations involving other intrafamilial offenders. Treatment issues for the offending fathers can be broadly defined as falling into three categories:
- issues related to the father's past sexual victimization of children,
- issues related to the father's possible future victimization of children, and
- other dysfunctional behaviors and problems.
These broad categories tend to be overlapping.
Issues Related to the Father's Past Sexual Abuse of Children
In many cases, the first challenge for the clinician is obtaining a confession of the sexual offenses. Many fathers are too ashamed to admit what they have done. Others are reluctant to disclose their abuse during litigation because they are afraid of its impact on the outcome. They may be more willing once the court case is resolved. Others are ordered into treatment by the court while continuing to protest their innocence.
Operationally, confession means an admission to all of the acts the child has described. However, it is common for the child not to disclose all of the abuse; therefore, it is important for the offender's therapist to stay in touch with the victim's therapist in case there are additional disclosures. (In treating intrafamilial sexual abuse, it is important for each family member to consent to share information with each therapist treating each family member.) To obtain a confession, the therapist actively confronts the father with the information on his offenses provided by the victim and others. In addition, group treatment, in which the father observes others confessing their victimizing behavior, can facilitate full disclosure.
With confession must come an acceptance of responsibility for the abusive acts. That is, the father must disavow any past excuses, such as his wife was not giving him sex or that he was drunk at the time. He must not minimize the behavior by saying, for example, "it only happened once," "there was no penetration involved," or "I stopped when she asked me to." As is probably apparent, it is extremely difficult to know when the offender has actually accepted responsibility rather than saying what he thinks the therapist wants to hear. Again, the use of group treatment can be especially helpful because other offenders may be more capable of discerning and confronting deception than a therapist.
A related task of treatment is for the father to appreciate the harm the abuse has caused the victim, his partner, and finally himself. There may be others affected as well, for example, siblings of the victim and the extended family. Some sort of communication from the victim and the offender's partner about the effects of the abuse on them can be useful. This may be in the form of a letter, a video or audiotape, or a face-to-face confrontation involving the therapist. Generic groups in which offenders are confronted by adult survivors and mothers of victims, other than the offender's own, can facilitate these insights. Written accounts, by victims, journalists, and professionals, of the impact on victims may be used, and offenders' groups can be the context for this work. As with the issue of responsibility, being sure the father is doing more than saying the right thing is a significant challenge.
At some point in treatment after the offender has confessed, taken responsibility, and come to appreciate the harm he has done, a series of apologies should be made. The offender must apologize to the victim, to his partner, and to the family in intrafamilial cases. There may be others who have been affected and deserve an apology as well. This is a process, not a single act, usually conducted in the context of dyadic or family treatment. The fact that the offender apologizes does not imply that the victim and others need to forgive him. These interventions need to be carefully orchestrated and controlled by the therapist. Only after the offender has completed the process, demonstrating an appreciation of the harm done, should his return home be considered.
A final treatment issue related to past abuse has to do with prevention. In order to prevent future sexual abuse, it is important for the offender and the therapist to understand why the offender sexually abuses children. In this regard, the model presented earlier in this chapter is relevant.
Thus, the treatment process involves coming to understand the offender's arousal pattern and why he acts on the arousal. Then contributing factors are explored.
Sexual arousal to children. Arousal patterns vary. They may be conceptualized as follows:
- Child is the offender's primary sexual object. Some offenders' sexual preference, sometimes exclusively, is for children. The term pedophile is generally used to refer to this type of offender. Often pedophiles not only prefer children, but children of a particular age and sex. Pedophiles tend to have multiple victims and actively seek opportunities whereby they can have sexual access to children, by choosing vocations and avocations that afford them contact with children. A contributing factor to this type of arousal pattern is often traumatic childhood sexual experience.120
- Child is one of multiple sexual objects. Other offenders have multiple paraphilias or aberrant sexual preferences and sometimes normal sexual preferences as well. The behavior of these offenders is characterized by sexual contact with children but may also include rape of adults, promiscuity with adults, exposure, voyeurism, sadomasochism, group sex, bestiality, and other sexual acts. The term sexual addict is often applied to this type of offender. The contributing factors or etiology of this pattern of sexuality appear to be a combination of childhood and adolescent experiences.
- Child is a situational sexual object. Finally, there are offenders whose normal sexual orientation is toward peers but who become aroused by children under certain circumstances. Factors that contribute to such arousal may include the absence of other sexual outlets, stresses affecting normal marital and/or peer relations and communications, child pornography, and physical exposure or contact to children that is sexually stimulating. Although initial sexual contact involving this type of offender may be situationally induced, the experience may be very gratifying. Clinical experience indicates this is likely to result in an increased desire for and preference for sex with children.
As may be apparent from the last point, although these three arousal patterns are presented as though they are discrete, they probably are not. For example, it may be inappropriate to classify some offenders as having either a primary orientation to children or to adults.
Understanding the offender's arousal patterns may be done by having the offender describe what he experiences about his victims as arousing, having him discuss in detail his sexually abusive behavior, having him reveal his sexual fantasies, or measuring his erectile responses to various visual and auditory sexual stimuli using the penile plethysmograph.* Treatment prognosis with pedophiles and sexual addicts is much poorer than for those who have situational sexual arousal to children.
The propensity to act on arousal. There is research that suggests that a substantial minority of the male population experiences sexual arousal to children.121 (Comparable research has not been conducted on women.) However, it appears that a great many more men experience these feelings than act on them. The willingness to act on these feelings appears to be related to one or in most cases more than one of the following deficits:
- pervasive superego deficits,
- circumscribed superego deficits,
- cognitive distortions,
- impulse control difficulties, and
- diminished capacity.
Persons whose superego deficits are pervasive have little or no conscience. The term psychopath is often applied to them. This condition is thought to be a result of early traumatic life experiences. Those who have some superego deficits may experience an absence of conscience related specifically to sexual activity or sexual activity with children, or they may generally have a weak or impaired superego. Some combination of early experience, lifestyle, and cultural norms may create this sort of superego. Differing in degree is the offender who has cognitive distortions related to his sexual deviance. He will have persuaded himself that sexual abuse is not bad or not so bad by such rationalizations as "The child won't know what I'm doing so it's not harmful" or "Everyone needs sex; this is my way." After the initial act, distortions may be "The child didn't resist, so she must have liked it," "There was no penetration so it wasn't really sexual abuse," or "It's my wife's fault because she withheld sex from me." Some offenders appreciate that what they do is wrong, but they do it anyway because they have poor impulse control.
Finally, some offenders experience diminished capacity, which enhances propensity to act on arousal. Typically, this is a temporary condition, and its most common cause is substance abuse. Thus, the offender acts on his arousal because alcohol or drugs have decreased his ability to control his behavior. Initial instances of victimization when drunk may occur without a prior plan. However, subsequently, the offender may drink so that he will have an excuse to abuse. Furthermore, after the initial acts, the attraction of the behavior itself may increase and chemicals are less necessary to diminish control. There can be other causes of diminished capacity. Offenders may lack adequate ability in handling stress, depression, anxiety, and/or anger in healthy ways. In addition, some persons suffer from chronic diminished capacity as a result of mental retardation or organic brain syndrome. If they experience arousal to children, it will make them at ongoing risk for sexual abuse.
Contributing factors. Some factors that may enhance arousal or increase the propensity to abuse have been described above. There may be other factors that act on these prerequisites and ones that independently contribute to risk for sexual abuse, for example, child behaviors, mother behaviors, and opportunity to sexually abuse.
It is an important part of the treatment process to understand why the offender has sexually abused children so that he can be empowered to gain control over his arousal and propensity to act on arousal. Some of the intervention that addresses contributing factors may be initiated with the offender alone, but much is done in the treatment of other individuals in the family and in dyadic and family work.
Issues Related to Possible Future Sexual Abuse
As noted in the previous section, preventing future sexual abuse relies on understanding what made the offender abuse in the first place. In this section, interventions that address arousal to children and propensity to act on arousal are discussed.
Sexual arousal to children. It has already been pointed out that sexual and other trauma during childhood may play a role in later sexual arousal to children. However, understanding the relationship of the offender's previous history to his arousal patterns is probably the least useful in prevention of future sexual abuse. In fact, often offenders manipulate the treatment process so that past history becomes an excuse for their offending. In spite of this risk, for some offenders, understanding the origins of previously incomprehensible behavior can render it manageable. Moreover, realizing that what the offender learned about sex roles as a child was wrong can lead to the development of more appropriate definitions of sex role behavior.
When deviant arousal patterns have been defined, the therapist will attempt to change these patterns. That is, the therapist will endeavor to decrease sexual arousal to children and increase arousal to appropriate sex objects. This is done through a variety of behavioral interventions that rely on both respondent and operant conditioning. These techniques include aversive conditioning, covert sensitization, thought stopping, masturbatory satiation, behavioral rehearsal, systematic desensitization, and masturbatory reconditioning. These techniques are often used in conjunction with social skills training, empathy training, and behavioral assignments.122
Behavioral interventions are exacting, and some require a laboratory setting. They also require the full cooperation of the client if they are to be successful. Moreover, the changes they create are not assumed to be permanent (nor are those from other types of intervention), and clients may need booster sessions. Many mental health professionals are untrained in and uncomfortable with behavioral interventions. However, to date they are the only therapeutic techniques that have been found, based on empirical evidence, to decrease sexual arousal.123 It behooves every clinician treating offenders to be familiar with these techniques and use those that can be suitably employed in his/her agency.
The propensity to act on arousal. Two approaches may be used to address propensity to act: techniques that enhance superego functioning by taking responsibility for sexual abuse and relapse prevention. Offenders whose propensity to act is based on pervasive superego deficits will probably not respond to treatment to reduce this propensity. However, those who have circumscribed superego deficits or are engaged in cognitive distortions probably will respond to interventions to address superego deficits. Treatment that is focused on getting the offender to take responsibility for his abusive behavior, to appreciate its harm, to acknowledge the feelings of traumatized parties, and to make amends or reparation is meant to enhance the offender's superego functioning and eliminate cognitive distortions, thus decreasing the probability of his acting on arousal in the future. Making amends or reparation usually involves a physical (e.g., community service) or monetary consequence that may serve to teach empathy and inhibit further abuse. In addition, when an offender lacks a strong internalized superego, the fact that there will be consequences for reoffense, such as prison or his wife leaving him, serves as an external superego. The strength of such interventions is in their deterrent effect.
In recent years, sex offender therapists have experienced success by using relapse prevention strategies, a technique borrowed from addiction treatment, in their intervention.124 Relapse prevention addresses propensity to act based on impulse control problems, reduced inhibition, and diminished capacity. Relapse prevention assumes that there are emotional states and behaviors on the offender's part that precede and ultimately precipitate the sexually abusive behavior. Often the offender is unaware of these factors and believes that his behavior is out of his control.
The clinician assists the offender in understanding these precursors and helps him develop a plan to manage such situations so that he does not reoffend. The clinician uses disclosures from the offender and others, including the victim, to obtain an accurate understanding of the circumstances that led to offending. Obviously such an intervention requires a candid and cooperative offender.
With some offenders, particularly those with cognitive limitations and difficulty being introspective, the clinician merely teaches the offender to anticipate, identify, and avoid risky situations. Thus, the offender may be instructed that he cannot assist at summer camp anymore or he cannot be left alone with his daughter.
With other offenders, the clinician helps him understand the chain of events, often seemingly unrelated to the sexual abuse, that precedes the victimization. This might include a series of procedures, such as the grooming process an offender may employ in the seduction of his victim, or acts such as getting upset with his wife and getting drunk after she goes to bed as a prelude to going into the daughter's room to molest her. The therapist then teaches the offender to interrupt the chain of events rather early while he still has control of his behavior. Thus, the pedophile is instructed to avoid driving by playgrounds, and the offender whose abuse is precipitated by drunkenness is instructed to abstain completely. If he has a serious substance abuse problem, he is sent to a substance abuse treatment program, either before treatment of his sexually abusive behavior is begun or in conjunction with sexual abuse treatment.
The relapse prevention plan is usually written out, and the offender carries it with him so he can refer to it when he thinks he is in a high-risk situation.
Interventions with the family mentioned earlier, such as not allowing the offender to be alone with the child or to discipline her, are meant to prevent him from being in high-risk situations. Moreover, there are numerous other ways the family and others can be involved in helping the offender prevent a relapse. Because most offenders experience more than one deficit leading to propensity to act, interventions that focus both on his taking responsibility and on relapse prevention are advised.
Other dysfunctional behaviors and problems. The offender may experience many other problems, and often these are contributing factors to the sexual abuse. Examples might be violent behavior, problems with the law, poor parenting skills, marital discord, poor social skills, low self-esteem, lack of education, and unemployment.
These are appropriate foci of treatment, and indeed it may be necessary to treat them because they increase the risk for future sexual abuse. Nevertheless, it is crucial that the clinician not allow him/herself to become sidetracked into only dealing with these other problems. Distraction can occur more easily than one might think if the offender refuses to admit to the sexual abuse or is reluctant to focus on it in treatment, yet is more than willing to work on his other problems. This pitfall is usually avoided if group therapy, which forces the offender to deal with his abuse, is a major component of the intervention and/or if there are several therapists involved in the case.
* The plethysmograph consists of a gauge attached to the offender's penis that can measure and systematically record tumescence.
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