Children Represent the Population
Children represent the population most frequently victimized by perpetrators of sexual abuse. The alarming statistics show that nearly 70% of all reported sexual assaults (including assaults on adults) occur to children ages 17 and under (Snyder, 2000). Furthermore, Adult retrospective studies show that 1 in 4 women and 1 in 6 men were sexually abused before the age of 18 (Centers for Disease Control and Prevention, 2006). Sexual abuse is defined as:
The involvement of a child in sexual activity that he or she does not fully comprehend, is unable to give informed consent to, or for which the child is not developmentally prepared and cannot give consent, or that violate the laws or social taboos of society. Child sexual abuse is evidenced by this activity between a child and an adult or another child who by age or development is in a relationship of responsibility, trust or power, the activity being intended to gratify or satisfy the needs of the other person.
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This may include but is not limited to: the inducement or coercion of a child to engage in any unlawful sexual activity; the exploitative use of child in prostitution or other unlawful sexual practices; the exploitative use of children in pornographic performances and materials (World Health Organization, 1999).
Child sexual abuse effects children across every ethnicity, religion, race and country. Factors that predispose a child to a greater probability of experiencing childhood sexual abuse include gender and family composition. Female children are victimized at a rate of five times more than male children (Sedlak, Mettenburg, Basena, Peta, McPherson, & Greene, 2010) and children who live in a home with a biological parent and non- married partner are at a twenty percent greater risk than children living with both biological parents (Sedlak, Mettenburg, Basena, Peta, McPherson, & Greene, 2010).
Perpetrators of child sexual abuse seek out vulnerable children whom they groom in order to abuse. The perpetrator seeks out ways to gain the child’s trust in order to later on exploit the child. The process through which the perpetrator gains the child’s trust and then sexually exploits the child has devastating psychological and emotional repercussions on the child. When abuse is perpetrated by a parent or sibling the damage is exponentially greater and calls into question the essential need of the child: connection.
Trauma devastatingly impacts a child’s secure attachment. When trust and attachment are exploited, a child’s sense of security and developed schemas are shattered. The development of trust in infancy provides the foundation for all future developmental milestones. Therefore, when trust is broken through a severe trauma, developmental regression may occur as a result.
Trauma focused cognitive behavioral therapy (TF- CBT) is an efficacious treatment model used to help children heal from sexual abuse in addition to other forms of trauma. TF- CBT involves multiple therapeutic techniques with the goal of helping the child rebuild his shattered schema, emotional wounds and memories of physical and emotional pain.
TF- CBT is present and future oriented; focused on helping the child heal from the trauma and the related behavioral, emotional and psychological effects, while focused on healing to promote healthy future relationships. To accomplish this TF- CBT employs numerous techniques represented by the acronym PRACTICE. Psychoeducation and parenting skills are essential in the healing of the traumatized child. A child who has experienced sexual abuse will look to the parent for reassurance, support, belief and hope. In order to provide for the child’s emotional needs, the therapist educates, coaches and provides empathy to the parent, in order for the parent to be an active part of the healing process. Parental participation in TF-CBT helps repair the child’s shattered trust.
Relaxation techniques, affective regulation techniques and cognitive coping skills are other parts of the therapeutic process. The therapist teaches the child and/ or parent how to channel difficult feelings and emotions. The therapist encourages the parent to support the child in healthy releases of emotion.
Trauma narrative is a cornerstone aspect of TF- CBT. Using the trauma narrative, the child recounts the trauma in extensive detail. The parent prepared and coached by the therapist, receives the narrative and provides encouragement, support and empathy. The parent’s supportive role in narrative therapy enables the child to rebuild the trust that lost.
In vivo mastery of trauma reminders is part of treatment used to help children effectively navigate situations that remind them of the trauma as opposed to them running away from these situations.
Enhancing safety and future relationship trajectory is an integral part of treatment and involves a discussion between the child, parent and therapist to ensure the child’s safety. Speaking openly about safety will enable the child to feel safe, cared for and protected, feelings necessary for redevelopment of attachment. Future relationship trajectory focuses on addressing issues resulting from the trauma which impact development of future relationships.
Eye movement desensitization reprocessing (EMDR) is a treatment model for trauma significantly different from TF- CBT albeit very successful. The theory behind EMDR is that the premise that the brain seeks to heal itself, and does. In cases where injury (trauma) is too great for the capacity of the individual to heal on his/ her own, the brain becomes stuck’ in an inability to heal and psychological and emotional distress is experienced (EMDR Institute, n.d.).
EMDR an acronym for Eye Movement Desensitization Reprocessing is a treatment in which an individual focuses on a traumatic memory, while simultaneously focused on external stimuli such as: following movement with the eyes, experiencing tapping on the hand, or listening to a sound (EMDR Institute, n.d.). The process of this simultaneous focus on internal and external experience helps access traumatic memories and create healthier connections to them.
The goal of EMDR treatment is help the client heal from the trauma by focusing on reprocessing emotions surrounding the trauma through a lens of adaptive beliefs and feelings. EMDR focuses on disconnecting associations made between the trauma and stimuli (such as sight, sound, taste) to promote healthful adaptive functioning in the present. EMDR treatment involves focusing on future events through the newly acquired integrated adaptive beliefs about the trauma, ones sense of self and the surrounding environment (EMDR Institute, n.d.).
EMDR is comprised of eight segments (often sessions) each with a distinct goal. Session one is focused on hearing the presenting problem, discussing EMDR treatment with the client and assessing if EMDR will be a good treatment choice for the client.
Session two involves empowering the client with tools to prepare the client for the process such as relaxation techniques, cognitive tools and emotional relaxation tools. Sessions three through six involve the eye movement desensitization reprocessing technique in which the client gains a more adaptive belief about the trauma, his/ herself and the physiological feelings that arise from the memory of the trauma. In session seven, the client reflects on a log created to discuss negative feelings that may have arose and coping skills on how to deal with them. Session eight, the closing session, focuses on progress made and how the treatment has facilitated healthier beliefs and awareness of what those healthier beliefs are (EMDR Institute, n.d.).
The following case study involves a ten year old sexually abused girl who is being treated using a Trauma Focused Cognitive Behavioral (TF- CBT) approach in conjunction with Child- Parent Psychotherapy (CPP).
Cara is a ten year old Caucasian girl who lives with her single mother Stacey. Stacey is very involved in Cara’s life, school and extracurricular activities. Stacey works very hard to provide for Cara, occasionally working late at her job as a paralegal. Cara comes to therapy following a recent disclosure to her mother that a neighbor, a 14 year old boy molested her. Cara, has been acting out behaviorally and showing signs of emotional distress, she is crying frequently, drawing pictures of distressed looking women and is having difficulty focusing on school- work. Most recently, Cara is showing disinterest in her friends.
In addition to Cara’s distress, are Stacey’s feelings of guilt surrounding her inability to prevent the abuse from having occured. Stacey blames herself for being at work the night Cara was molested and is beginning to doubt her own ability to successfully parent Cara.
In this case, the social worker will employ TF- CBT as a trauma intervention. For the first meeting Stacey comes by herself. Stacey is fearful about the changes she has seen in Cara, feeling extraordinarily guilty and overall distressed. Stacey mentions she is concerned about leaving Cara alone after school when she has to work overtime. Together, we work out a plan to ensure safe supervision for Cara. Stacey suggests she involves her parents who live nearby and can watch Cara on the nights she has to stay late. We discuss keeping Cara safe will necessitate she be with a trustworthy adult when Stacey is at work, this will also enable Cara to feel safe when Stacey is not around.
I outline what Trauma Focused Cognitive Behavioral Therapy involves and Cara seems interested in pursuing this form of treatment. In brief, I describe the effect of sexual abuse on a child and explain that the symptoms Cara is experiencing are consistent with child sexual abuse occurrence and reassure her that together we will help Cara heal. I reassure Stacey that I am here to support her through the process and emphasize that as Cara’s mom she plays the most important role in helping Cara heal. We discuss the trauma narrative and the fundamental role she plays in supporting Cara through this process. Stacey and I briefly discuss some relaxation techniques that she can use. I discuss with her what therapy with Cara will look like. We agree that Cara, Stacey and I will meet next week, followed by sessions with Cara to learn relaxation techniques and to begin working on the trauma narrative. I assure Stacey that she can reach out to me for support when necessary.
In meeting with Cara, I learn that Cara is deeply fearful and experiences a great deal of self- doubt and insecurity about her body. At this pre-pubertal stage, Cara experiences many conflicting feelings about her body, she is feeling self- hatred and disgust combined with curiosity. Cara is angry that her mom for having left her alone which is when she was molested. Cara feels tremendous guilt for not preventing the abuse.
Cara and I discuss that the abuse is not her fault. The abuser is one hundred percent responsible for his actions. You did nothing wrong I tell her. We discuss some of the difficult feelings she experiences. Cara and I review some deep breathing techniques and ways to redirect her thoughts when they enter a depressive loop. Cara and I discuss that her mom is here to support her and that we will meet with her mom occasionally within treatment. Cara is uncomfortable with the trauma narrative. Cara tells me she likes to draw and we agree that she will draw pictures representing her feelings of what happened.
As Cara and I continue to meet, I experience some transference coming from her. Her disbelief in me that I care is reminiscent to the way she feels about her mom and her anger towards her for having left her alone. Cara and I work through the feeling of anger she has towards her mother through the trauma narrative. In our joint session, Stacey expresses her remorse for leaving her alone and together they discuss a plan that if Stacey has to leave somewhere she will ensure that Cara has safe supervision. Stacey has informed the neighbor’s mother that her son molested Cara and after initial resistance the mother has placed her son in therapy. Cara is aware that this neighbor’s son is in treatment and under supervision to ensure that he is not in a position to perpetrate further abuse.
At the end of TF- CBT Cara is experiencing significantly fewer symptoms of trauma. Nonetheless, Stacey hesitantly expresses concern that her relationship with Cara has not been the same since the incident of molestation in spite of treatment. I assure Stacey that with time the techniques she has learned will help Cara re-develop trust. Stacey is not calmed.
I ask Stacey to explain her anxiety, she shares that since hearing Cara’s narrative she has begun to feel out of control’ of her emotions, she feels like a weak parent and unable to enforce already established household rules. Stacey reflects that perhaps her own experience with childhood abuse has led to this feeling of insecurity.
Stacey and I work together using cognitive behavioral therapy to help Stacey maintain her position of authority as parent and to prevent her from being derailed by Cara’s experience. We focus on breathing techniques, repairing cognitive distortions and maintaining calmness in face of triggers. As Stacey gains insight into her experience of abuse, she feels greater ability in continuing to help Cara throughout the process of healing. I caution Stacey not to share her own experience with Cara as that will reinforce her own negative schemas. Stacey reflects that in spite of her own experience she leads a fulfilling life and feels that knowledge of her own experience will empower her to help Cara to do the same.
Stacey’s commitment to Cara’s recovery will enable Cara to overcome this trauma. Stacey’s willingness to engage in treatment and support Cara will empower Cara to re- establish a trusting relationship with her mother. In spite of Stacey being a single mother, with her parents help, Stacey will ensure that Cara is not left without supervision.