Child Sexual Abuse : Treatment Issues

by Child Welfare Information Gateway

(Page 5 of 11)

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.

Trust

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. 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. 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.

About the Author

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