Group Counseling with Children Who Have Been Sexually Abused: Manual

Trica L. Peterson, B.A., Ph.D. student

Deborah A. Gerrity, Assistant Professor

Counseling Educational School of Psychology

University at Buffalo/CDHS Partnership

Jere Wrightsman, Unit Director

Foster Care

Acknowledgement:

This research project was funded by the Office of Children and Family Services, Award: 27276, Project: 1029154, Task 2 through the Center for Development of Human Services, Research Foundation SUNY, Buffalo State College.

Purpose of the Manual………………………………………………………………………….3

General Child Sexual Abuse Information………………………………………………………4

Definitions & Prevalence….……………………………………………………………4

Behavioral and Psychological Impact………………………………………….……….4

Severity of Aftereffects…………………………………………………………………7

Aftereffects by Age Group…………………………………………………………..….9

Aftereffects by Gender……………………………………………………………...…10

Family Characteristics …………………………………………………………..…….11

CSA Group Treatment…………………………………………………………………………11

Advantages of Group Treatment………………………………………………….……11

Therapeutic Issues………………………………………………………………….…..12

Group Screening, Structure and Topics…………………………………………….…..13

Group Format by Age…………………………………………….…….…………..…..14

Format for Pre-School Groups………………………….….…….…………..…14

Format for Latency Groups………………………………….…….………..…..17

Group Activities by Age………………………………………..………….……...…….19

Pre-School Group Activities………………….………..………….….……..…..19

Latency Group Activities……………………………..…………….…..………20

Group Counseling Services in Buffalo Area…………………………….……………….……..23

References………………………………………………………………………………………24

Purpose of this Manual

This manual is intended to highlight some of the crucial information that counselors should have before attempting to conduct a sexual abuse group for preschool or latency aged children. It is in no way meant to replace any formal training and is not considered exhaustive in its content. The references provided at the end of the manual do, however, provide a pretty comprehensive look at group therapy for children who have been sexually abused. It is recommended that potential therapists read the relevant literature on CSA groups before attempting to conduct one on their own. Group therapists should be licensed practitioners with training in group therapy, normal sexual development, and sexual abuse sequelae and have experience working with sexually abused children. In order to abide by APA’s ethical guidelines of competency, it is suggested that new therapists co-lead a group with a more experienced therapist in the realm of children sexual abuse before running a group on their own. Conducting a group for sexually abused children is more complicated and emotionally draining than most other forms of group therapy. Therefore, it is also imperative that group therapists receive adequate supervision throughout the course of the group.

Group Counseling with Children Who Have Been Sexually Abused

General Child Sexual Abuse Information

Definition and Prevalence

Child sexual abuse (CSA) involves any sexual activity with a child where consent either is not, or cannot be, given (Finkelhor, 1979). This includes sexual contact that is accomplished by force or threat of force, regardless of age. All sexual contact between an adult and a child, regardless of the child’s understanding of the nature of the activity is considered sexual abuse (Berliner & Elliot, 1996). There are a variety of behaviors and activities that constitute sexual abuse. They include sexual penetration, touching, and non-contact sexual acts, such as exposure or voyeurism (Berliner & Elliot, 1996). Incest is child sexual abuse that occurs between family members, including blood relatives, stepparents, in-laws and extended family (Finkelhor, 1979).

CSA is a widespread problem that demands significant attention. Large-scale community surveys indicate that approximately 25 % of girls and 10% of boys have been sexually abused before the age of eighteen (Cosentino, Meyer-Bahlburg, Alpert, Weinberg, & Gaines, 1995). Briere (1992) estimates the prevalence of child sexual abuse amongst females in the United States to be between twenty and thirty percent of the population. A survey of female college students conducted by Russell (1984) indicated 54% of her subjects had atleast one occasion of sexual misuse ranging from exposure to sexual intercourse before reaching adulthood. Finkelhor (1994) found that 3 to 29% of men had experienced an incident of CSA.

Behavioral and Psychological Impact

With only a few exceptions, most of the studies conducted within the last ten years in the area of CSA have found a link between reports of CSA and subsequent mental health problems (Berliner & Elliot, 1993; Trowell et al., 2002). Finkelhor (1998) has described a traumagenic dynamics model of sexual abuse to explain the unique factors associated with the experience of CSA. The model acknowledges the different effects of CSA depending on the nature of the abuse while specifying its impact on a child’s development. The model consisted of four key experiences that alter a child’s cognitive or emotional orientation to the world and distort the child’s self-concept, view of others and affective functioning (Alpert, Browne & Courtois, 1998; Finkelhor, 1998; Spaccarelli, 1994).

The first experience is called traumatic sexualization. This involves exposure to sexual experiences that are developmentally inappropriate. Traumatic sexualization is thought to increase sexual acting out, confusion regarding sexual identity, and compulsive sexuality or sexual aversion. (Finkelhor, 1998).

Powerlessness, the second experience in Finkelhor’s model, denotes the inability of the child to stop, or prevent, the abuse. This experience is thought to cause anxiety, a tendency to see oneself as a victim in a multitude of situations and may lead to identification with the perpetrator. Some behavioral outcomes of this experience are somatic complaints, depression, dissociation, sexually aggressive behavior and phobias (Finkelhor, 1998).

Thirdly, stigmatization occurs when negative connotations of the experience are communicated to the child. This is thought to lower self-esteem, and cause feelings of shame and guilt. Stigmatization often leads to substance abuse, social isolation, suicidality and self-harm behaviors (Finkelhor, 1998).

Realization that a trusted person has manipulated or failed to protect the child comprises the fourth and final experience explained in the model. This experience of betrayal shatters the child’s confidence that trusted people are capable of protecting them. When experiencing this stage of the model, children often exhibit clingy behavior. They additionally display conduct problems, mistrust, grief, and anger (Finkelhor, 1998).

In general, researchers agree that children who have been sexually abused evidence more negative psychological symptoms than do their similar aged, non-abused peers. Findings by Kendall-Tackett, Williams, and Finkelhor (1993) support this view, showing that sexually abused children in their review had more symptoms than non-abused children, with abuse accounting for 15 to 45% of the variance. The aftereffects of CSA however, have a vast range from mild emotional or behavior problems, such as low self esteem and poor school or work performance, to severe psychopathology, such as post traumatic stress, depression, anxiety and various personality disorders. For preschoolers, the most common symptoms were anxiety, nightmares, PTSD, internalizing and externalizing, and inappropriate sexual behavior. For school aged children, the most common symptoms included fear, neurotic and general mental illness, aggression, nightmares, school problems, hyperactivity, and regressive behavior (i.e., enuresis, encopresis, tantrums). Among adolescents, symptoms included depression, withdrawal, suicidal, self-injurious behavior, somatic complaints, illegal acts, running away, and substance abuse.

There is no one-to-one correspondence between a history of sexual abuse and any specific psychiatric diagnoses, yet a history of childhood sexual abuse is an important risk factor found in clinical populations at a rate that is greater than the expected rate would be if sexual abuse were a random factor (Alpert et al., 1998). These diagnoses include: borderline personality disorder and other Axis II disorders, affective disorders, eating disorders of varying severity, dissociative disorders, and addictive disorders (Berliner & Elliot, 1996).

CSA survivors are also likely to develop symptoms related to Post-Traumatic Stress Disorder (PTSD). The risk for developing PTSD is especially high if the abuse involved penetration or force (Heffernan & Cloitre, 2000; Kendall-Tackett et al., 1993). In the literature, a prevalence rate of almost 50% for PTSD exists among survivors of childhood sexual abuse (Kendall-Tackett et al.). The major identifying symptoms of PTSD in children are nightmares, fears, and guilt (Kendall-Tackett et al., 1993). Symptoms of posttraumatic stress also include intrusive re-experiencing symptoms, numbing and detachment symptoms, hyper-arousal, startle response, sleep disturbance, as well as dissociative features and mechanisms, such as psychogenic amnesia, fugue, de-realization and depersonalization (Alpert et al., 1998).

Overall, there is no one syndrome or symptom that is found in all victims of sexual abuse. In fact, up to 50% of children who have been sexually abused may be asymptomatic (Beutler et al., 1994 as cited in Hansen, Hecht, & Futa, 1998). It is unclear, however, what causes some children to have severe symptoms and some to show no outward aftereffects of abuse.

Severity of Aftereffects

Through empirical investigation, numerous variables have been identified that appear to influence the impact that sexual abuse has on children. First, age at time of assessment seems to be a common intervening variable. Kendall-Tackett et al. (1993) found that older children had more symptoms than younger children. Unfortunately, these studies did not control for other factors relating to the abuse, such as duration, in that the older children may have experienced the abuse longer or endured more severe types of molestation.

Age of onset of abuse is another possible intervening variable. Studies have shown early age of onset to be associated with amnesia among adult survivors and late presentation for treatment, thus increasing the impact of the aftereffects of the sexual abuse (Kendall-Tackett et al., 1993). It is unclear whether late presentation is associated with amnesia or occurs as a result of the early onset of abuse.

Kendall-Tackett et al. (1993) also found that abuse involving violence, penetration, multiple offenders, more frequent occurrences, and a closer relationship with the offender appear to result in a greater psychological and behavioral impact. Likewise, molestations that included some form of penetration were more likely to produce more symptoms than molestations that did not. Lastly, these researchers found that the identity of the perpetrator is another factor related to the impact of abuse, with perpetrators who are close to their victims, usually fathers or stepfathers, resulting in greater impact of abuse on the child (Kendall-Tackett et al., 1993).

Kendall-Tackett, Meyer, and Finkelhor (1993) found little consistency in differences in symptomology related to gender. Research on the long-term effects of sexual abuse has tended to focus on the sequelae in women. Females have a tendency to internalize their traumatizing symptom effects by showing more signs of anxiety, fear and depression (Kendall-Tackett et al. 1993; Finkelhor, 1990; Spacarelli, 1994). Alternatively, males seem to have a tendency to cope with their abuse by externalizing their distress, often displaying aggression and anger. They tend to manifest their anxiety through sexual and physical aggressiveness (Scott, 1992). Additionally, boys may have a heightened preoccupation with sexual activity, a generalized attitude of hyper-masculinity (aggressiveness, explosions of temper, discouraged expression of vulnerability) and extreme fear of homosexuality. This homophobia makes boys rigid in expression of typical male characteristics, i.e. machismo, and instills a fear of close relationships with other males. Zamanian and Adams (1997) support many of Scott’s assertions in that they have found that male victims often perceive themselves as emotionally and physically weak for being the object of abuse. These authors assert that male victims will display aggression and a hyper-masculine stance, sexual identity confusion, and may have a compulsion to repeat their experiences in a masochistic or sadistic way. Scott also notes the relationship of male victimization and externalized expression with the high occurrence of perpetrators being men. Reinhart (1987) found that 96% perpetrators whose victims were males are men. Scott believes this victim/victimizer pattern is a means of protection so as not to be re-victimized.

Sexualized behavior is considered the most characteristic symptom of CSA in children. It is displayed throughout the different age ranges in various manifestations and has distinguished CSA children from non-abused children in general and psychiatric settings (Constentino et al., 1995). Kendall-Tackett et al. specify sexualized play with dolls, excessive or public masturbation, seductive behavior, and age inappropriate sexual knowledge as possible indicators of CSA. In addition, children will often blame themselves for break up of their family, feel shame regarding the abuse and suffer from low self -esteem. They may have an inability to trust others, become withdrawn, avoid eye contact, have sleeping or eating problems, and may experience flashbacks of the abuse.

Aftereffects by age group

In addition to the aftereffects mentioned above, a list has been provided here by age group. For preschoolers, the most common symptoms were anxiety, nightmares, PTSD, depression, aggression, and inappropriate sexual behavior. For school aged children, the most common symptoms included fear, neurotic and general mental illness, aggression, nightmares, school problems, hyperactivity, and regressive behavior (i.e., bed wetting and soiling, tantrums). Among adolescents, symptoms included depression, withdrawal, suicidal, self-injurious behavior, somatic complaints, illegal acts, running away and substance abuse.

Aftereffects by gender

Females have a tendency to internalize their traumatizing symptom effects by showing more signs of anxiety, fear and depression (Kendall-Tackett et al. 1993; Finkelhor, 1990; Spacarelli, 1994). Alternatively, males seem to have a tendency to cope with their abuse by externalizing their distress, often displaying aggression and anger. They tend to manifest their anxiety through sexual and physical aggressiveness (Scott, 1992). Additionally boys may have a heightened preoccupation with sexual activity, a generalized attitude of hyper-masculinity (aggressiveness, explosions of temper, discouraged expression of vulnerability) and extreme fear of homosexuality. This homophobia makes boys rigid in expression of typical male characteristics i.e. machismo, and instills a fear of close relationships with other males. Zamanian and Adams (1997) support many of Scott’s assertions in that they have found that male victims often perceive themselves as emotionally and physically weak for being the object of abuse. These authors assert that male victims will display aggression and a hyper-masculine stance, sexual identity confusion, and may have a compulsion to repeat their experiences in a masochistic or sadistic way. Scott also notes the relationship of male victimization and externalized expression with the high occurrence of perpetrators being men. Reinhart (1987) found that 96% perpetrators whose victims were males are men. Scott believes this victim/victimizer pattern is a means of protection so as not to be re-victimized.

Family Characteristics

Families with a child who has been sexually abused are thought to have certain common characteristics. Berliner and Elliot (1996) report that families of incest and non- incest abuse are less cohesive and generally more dysfunctional than families of non-abused children. The problem areas identified are in the areas of communication, social isolation, and lack of emotional closeness and flexibility. Parental psychopathology, domestic violence and marital conflict were also seen as risk factors for CSA. Additionally, children from a single parent home, whose mother is unavailable or whose mother had a history of abuse are at increased risk for sexual victimization (Nolan et al., 2002). In over one third of the cases studied by Nolan et al. (2002), mothers had a history of abuse.

Recent studies indicate that sexual abuse occurs without regard to race, ethnicity, or SES. Unlike other forms of abuse, socio-economic status does not appear to be related to sexual abuse (Berliner & Elliot, 1996). Finkelhor (1979) indicated that pre-adolescent children were most vulnerable to sexual abuse, however, sexual abuse has been reported from ages as young as three months.

CSA Group Treatment

Advantages of Group Treatment

Gerrity and Peterson (in press) explain that CSA treatment can be long-term and utilize multiple methods and techniques due to the impact of the abuse, the time between abuse occurrence and actual treatment for symptoms, and the overall complexity of posttraumatic reactions. Finkelhor (1986) identified four causes of the trauma: sexualization, stigmatization, betrayal, and powerlessness, which have been described elsewhere in this paper. In general, therapists are attempting to assist the children in reviewing the abuse and in working through all of the aftereffects.

Briere (1996) explains that group has advantages over individual therapy in that it lessens isolation and stigmatization, reduces shame, and provides the client with the opportunity to help as well as be helped. Talbot et al. (1998) also related that therapy with a peer group reduces the perceived power of the authority figures, through interaction with group leaders, and helps break down resistance and regression that may occur in individual treatment. Forseth and Brown (1981) also stated that three-quarters of programs offering treatment for abused children provided group interventions.

Therapeutic Issues

It is imperative that leaders be cognizant of potential legal issues, sexual abuse aftereffects, and general group therapy techniques (Knight, 1997). Since group members may disclose continuing or current abuse of someone else in their family, knowledge of legal statues regarding mandated reporting of abuse is also critical. For a more complete list of concerns that leaders should attend to before starting a sexual abuse group for children, please read the “Purpose of this Manual” section of this paper. Many authors agree that CSA groups should be co-led (Courtois, 1993; Knight, 1997), in order to buffer the stress and risk of burnout. Utilizing a co-leader to review personal reactions, group dynamics, and countertransference issues is valuable.

The availability of a co-leader can be helpful in both prevention (due to sharing of stress and processing of group) and early detection of problems. In addition, co-leaders can model healthy discussion and confrontation as they interact with each other within the group sessions (Herman, 1992). It may be the first time that members have seen healthy discussion and tolerance of differences.

Group Counseling with Children Who Have Been Sexually Abused: Manual