By Helen Kambouridis MAPS and Mary Raftopoulos, The Gatehouse* at the Royal Children’s Hospital, Melbourne

Working with children who have experienced sexual abuse presents unique challenges for the treating therapist. These include: working with very young children who do not have the capacity or willingness to verbalise their experiences; working with complex families and presentations of intergenerational trauma; and working with broader care and statutory systems. This article outlines The Gatehouse’s approach of working therapeutically in this complex field.

Screening

Referrals to The Gatehouse are screened by the duty worker with the aim of ensuring they receive the most appropriate response.

A 3-year-old girl in the bath points to her vagina and says “hurting”. Asked why, the child said, “Daddy hurted it. Daddy wiped too hard”. The mother calls the duty service in tears, talking about wanting to protect her daughter from her violent ex-husband (the child’s father). She talks about her own abuse history and her fear that her own child could be abused the way she was.

 

In deciding whether this child needs an assessment at a sexual assault centre, the duty worker in this instance needs to consider evidence of:

  • Symptomatic behaviour that may be consistent with suspected sexual abuse
  • Problem sexual behaviour
  • Inappropriate boundaries in the family’s life
  • Custody issues regarding the care of the child
  • Family violence
  • Possible unresolved trauma related to the mother’s own sexual abuse, in order to consider other more appropriate service options for this parent at this stage.

Assessment phase

Following acceptance of the referral, the child is assessed, typically over 6-8 sessions to ascertain the impact of the alleged sexual abuse or problem. The assessment is not a fact finding mission as to whether sexual abuse has occurred. Parents are advised that child protection (DHS) must be informed if there are concerns about their child’s safety. This can be a fine distinction and you might wonder how an assessment of impact can be conducted by a psychologist if it remains unclear if child sexual abuse (CSA) has actually occurred. Given that it is less frequently substantiated than other forms of child abuse (Australian Institute of Family Studies, 2013; Australian Institute of Health and Welfare, 2013) and alleged perpetrators are rarely prosecuted (Victorian Law Reform Commission, 2004), the simple fact remains that we often do not have indisputable evidence, but we do have children with concerning behaviour that could be indicative of an experience of sexual abuse. And as we know, the domains of experience explored by a psychologist are not often simple, clear territories, but ones which we must enter with a mind open to many possibilities and, as much as possible, free of preconceived judgements and ideas.

The assessment process raises a new question: Is this child ready for therapy?

DHS refer a 7-year-old boy with a chronic history of abuse including long-term sexual abuse by a grandfather. The boy’s mother is a substance abuser and his father in prison. The boy was in the care of extended family who are no longer willing to care for him. After three unsuccessful foster placements, he is in a residential unit. He attends primary school part-time due to behavioural difficulties, including smearing faeces, problem sexual behaviour towards his peers and adults, and poor self-regulation.

 

It is a crucial question for the therapist to consider. Children need parents or carers who are permanent, reliable and committed to their care so that therapy (and the therapist) does not feel like an intrusion. A stable external environment is needed to counteract internal turmoil and to enable fantasies to be explored safely (Dyke, 1987). An assessment may be threatening to a child who has “not established a safe enough base-line from which…to explore the phantasies evoked in the play” (Dyke, 1987, p. 77).

Containing the anxiety experienced by professionals involved in this child’s life may be a more appropriate intervention for the psychologist to offer in this case. Care teams who support children with numerous traumatic stressors frequently display a parallel process: the client’s dysregulation and lack of inner containment is reflected in the key workers’ difficulties in holding on to their ‘sanity’. Splitting within a team and ‘spilling over’ occur; blame for the child’s circumstances is projected and a desperate need for a ‘parent’ to ‘take charge’ and ‘fix’ the child evolves. Enter the psychologist who can feel pressured to see this child. However, at the very least, a child needs a stable home placement and the same caregiver to bring them in to treatment. In the absence of this stability, a therapist may provide the support needed to the care team through:

  • Bringing to awareness the child’s personality traits that may elicit positive, nurturing responses from the adults in their environment
  • Providing practical strategies to manage challenging behaviours
  • Attending regular care team meetings with DHS, residential staff, and teachers to provide secondary consultation, review progress and share ‘good news’ stories
  • Encouraging all the professionals’ ongoing good work and support of the child and help in maintaining hope.

Treatment approaches

Not all children and young people referred to The Gatehouse are seen for treatment. For some, the assessment is the intervention. For others, more prescient needs that could be met in a more appropriate setting need to be addressed first. However, for those who do continue into a treatment phase, the question is how best to work with this case?

At kindergarden, a 4-year-old girl talked about “sex games”. Her mother reported that she was inserting objects into her vagina and was preoccupied with her baby brother’s penis. Her compulsive masturbating cannot be redirected. During assessment, the child refused to answer any questions from the therapist, could not maintain eye contact and her conversation made little sense.

 

Traditional ‘talk therapy’ will not meet this child’s need. Play is a child’s language and toys their words (Landreth, 2012). Furthermore, stimulating the right hemisphere of the brain, which responds to non-verbal modalities such as play, art, music and sandplay therapy, may assist in the processing of trauma (Gil, 2006). Interventions which create a sense of pleasure and mastery, “safety, predictability and fun” can foster self-regulation skill development (van der Kolk, 2005, p. 407).

Non-directive play therapy offers a safe environment where a child may disclose his or her secret trauma, as did the little girl in the vignette above. Initially her behaviour – not her words – communicated her distress.  The window to the inner world of traumatised children is often through their behaviour and play. For older children and adolescents, art therapy and approaches that facilitate a sense of acceptance, empowerment and the making of meaning are of great value.

A 6-year-old girl angrily told her parents that her adolescent brothers won’t play with her even though she did “lick their doodles”. The parents confront their sons who deny abuse, but the little girl, a precious unexpected daughter born after an illness that nearly took their mother’s life, provides far too much detail to be discounted. The boys have had access and opportunity against the backdrop of dealing with their own trauma in relation to family events. Their parents don’t know who to support, how to support them, or how to make their family OK again.

 

Working with cases of sibling sexual abuse adds yet another level of complexity for psychologists treating presentations of CSA (Kambouridis, 2013). Where do you begin? Whose story do you hear first? Safety from further abuse – sexual or otherwise – is crucial, but what will safety look like for: the abused child whose integrity has been attacked and who may feel both blamed and responsible; the parents whose identity as parents has been crushed by shame, blame, anger and grief; or the child who has perpetrated the abuse who is also frantically defending against the effects of shame and the fear of rejection and abandonment?

As a therapist, the capacity to hold the frequently competing narratives and needs of the different family members in mind and ride the roller coaster of denial and acceptance with which families present is critical and at times both confronting and draining. Using a combination of individual and family therapy to help clients put words and meaning to both their experience and their hope for what might become of their family is often the focus of such work. In addition, psycho-education can help the family to understand their experience and challenge the constraints of damning, blaming and shaming narratives, while regular consultation with colleagues is essential for the therapist to remain aware of, and hopefully disentangled from, the parallel processes that can be heightened in these presentations.

Conclusion

We have chosen breadth of issues in this article rather than depth. There is, of course, much written elsewhere about CSA and its treatment. At The Gatehouse however, providing a child- and family-friendly environment of non-judgment supports our clients to find the courage to go back to their frightening experiences and explore them with a sense of safety and control. The therapist’s capacity to be receptive, sit with, recognise, digest, process and self-regulate the client’s projections is integral as we bear witness to their immense pain, and ultimately work with them to create a narrative of hope and growth that they can take forward with them once they leave therapy.

The first author can be contacted at Helen.Kambouridis@rch.org.au

* The Gatehouse Centre is part of both the Royal Children’s Hospital in Melbourne and the Victorian Centres Against Sexual Assault (CASA). It provides assessment and treatment for children and their families who have experienced sexual abuse, with referrals coming from a range of sources including parents, caregivers, child protection (Victorian Department of Human Services [DHS]), the police and schools.

References

  • Australian Institue of Health & Welfare (2013). Child Protection. Available at: http://www.aihw.gov.au/child-protection
  • Australian Institute of Family Studies. (2013). Child Abuse and Abuse Statistics. Available at: http://www.aifs.gov.au/cfca/pubs/factsheets/a142086
  • Dyke, S. (1987). Saying “no” to psychotherapy: Consultation and assessment in a case of sexual abuse. Journal of Child Psychotherapy, 13(2), 65-79.
  • Gil, E. (2006). Helping abused and traumatised children: integrating directive and non-directive approaches. N.Y: The Guilford Press.
  • Kambouridis, H. (2013). Using co-operative inquiry and participatory action research with therapists in the Victorian sexual assault field to better deliver services to families who have experienced sibling sexual abuse. In S. Goff (Ed.) From theory to practice; Context in praxis: 8th Action Learning, Action Research and 12th Participatory Action Research World Congress proceedings, 2010.
  • Landreth, G. L. (2012). Play therapy: the art of the relationship. NY: Brunner-Routledge.
  • Van der Kolk, B. (2005). Developmental trauma disorder: Towards a rational diagnosis for children with complex trauma histories. Psychiatric Annals, 35(5), 401-408.

InPsych October 2013