Foyle Children's Resource Team, NPSCC

"Clinical practice should be driven by theory and research findings. However, the treatment of abused children is often atheoretical and consists of a variety of generic treatment techniques. In addition, research into treatment efficacy with abused children only now is emerging". (Friedrich, 1990, p.104)

Applying theory to practice shapes one of the central planks in our assessment of the impact which sexual abuse has on children and their families. Our focus falls on family functioning prior to disclosure of abuse, the child’s initial response and coping resources, parents/carers initial response and coping resources, the impact which other agencies will have had on the situation and the response/attitudes of the wider community.

Assessment involves review and evaluation of the following:

2. Reports by other professionals. Education, health and psychological reports form an important part of the assessment. Details of other counselling services provided are also be sought.

3. Information shared by parents/carers and other family members. This aspect of assessment will have implications for recovery given the central role of parents in the therapeutic process.

Assessment is not a one-off exercise which precedes the offer of a service but a process which continues throughout the period of therapeutic intervention. At the point at which a referral is accepted by the team, it is allocated to a key-worker and co-worker who acts in a consultative role. The two workers plan for each session and the key-worker carries out the direct intervention with the child or family. Following each session the key-worker and co-worker meet to debrief and plan ahead. A team approach is seen as crucial to the therapeutic process and weekly team discussions are held to assess, plan and review work with the children and families. The team uses a variety of tools and approaches to gather information. One example of an assessment tool used in helping to establish the traumatic symptoms the child is suffering is a Measuring Scale and Checklist taken from Spinal Robinson and Easton Wickham (1993). Through these worksheets children identify their trauma symptoms, which enables the team to establish what area of work needs to be carried out. Consideration is given to the importance of allowing the child a sense of control over what he/she wishes to discuss and as such allows him/her choice about which area of work they wish to address first.

Although the preliminaries have been completed we do not make any assumptions about the child’s understanding of why they are coming to see us. This is one amongst other questions, which will be addressed in the initial individual sessions with the child. It is most important for the child to understand that he/she is attending counselling sessions in order to deal with any problems arising out of their experiences of abuse. Other questions to be addressed at this stage include the child’s current situation and with whom he/she is living, his/her reactions and feelings about this, perceptions of the relationship with parents and peers and the child’s likes and dislikes. In addition to clarifying the purpose of our involvement, the initial session also sees the beginning of the relationship building and of the getting to know the whole child’ which is essential to recovery work.

As the process of getting to know the child continues, the emphasis will shift to the area of identifying trauma symptoms (e.g., guilt, anger, self blame, night-mares, flashbacks, etc). It is not uncommon at this stage for the child to identify sources of trauma, which are not sexual abuse specific. For example, parent’s difficulties with alcohol and drug abuse or extremely poor parent/child relationships. One negative aspect of the latter could be the absence of a positive attachment relationship, which is so crucial to the recovery process.
A recent example of this was a seven year old girl who was received into care following multiple abuse. The residential home in which she was placed was not conducive to forming the essential attachment relationship which was sadly lacking. The team advocated on her behalf in seeking a specialist foster placement. For this child the benefits of a secure home environment became evident in the way in which she engaged in and completed the therapeutic work (although there may be occasions in the future when she will require further counselling in response to life stages and events).
In circumstances where other sources of trauma have been identified by the child we will step back from the issues related only to sexual abuse to help the child deal with what is uppermost in their order of priorities. The aforementioned child clearly identified her natural parent’s alcohol abuse as more traumatic than her sexual abuse. Therefore this became the prime focus of the team’s work with her.
Enabling children to identify and regulate the emotions associated with sexual abuse is an important part of our work. However, the persistence of issues such as self-blame, self-harm and relationship difficulties present a much greater challenge. This invariably means taking on the task of correcting cognitive distortions.

James encourages a therapeutic approach, which enables the child to return to the pain’ in a way which is reality-based. A developmentally sequenced approach to planning and intervention is suggested. Similarly, Friedrich (1990) is in favour of promoting a full description of the traumatic event, despite a rising level of anxiety. Our practice is greatly influenced by this approach, with the result that the therapeutic relationship with the child and family can extend over a period of some years. Intervention will be periodic and essentially determined by what is current for the child. In the case of young children, sexual abuse may be experienced generally as confusing and disagreeable whilst at a later stage guilt and shame might well predominate. In the teen years problems associated with self-esteem, self-harm and relationship difficulties are often more prevalent.

Engaging children in the process of addressing issues arising out of the trauma of sexual abuse is fraught with difficulty. It is especially difficult for them to communicate complex and conflicting emotions. In considering this issue we should not assume that because a child has attained an age and verbal capacity, which enhances every day functioning, that this will be adequate when he/she is faced with a situation which is generally beyond a child’s comprehension. In offering the child a wide variety of approaches to communication, including free play, structured play, reading, writing and drawing, he/she is able to learn communication tools which will improve the possibility of overcoming these difficulties.
A child friendly environment is absolutely critical if the child is to feel comfortable and relaxed. From this point of view much emphasis is placed on a physical, warm, friendly environment where the child meets all staff and is made feel welcome. Therapy rooms have recently been refurbished and the children and young people’s views were sought as to the choice of decor used. From the very first contact our approach is one in which communication with children is determined by their age, abilities and developmental level. Our approach to the work, verbal or non-verbal, will be tailored to the needs of the individual child thereby avoiding a curriculum approach.
Developmental considerations are critical to our planned intervention and on occasion we find it necessary to refer to another professional, for example a community medical officer, for developmental assessment. This is in keeping with our commitment to an interdisciplinary approach to practice in cases of child sexual abuse.

INVOLVING PARENTS I CARERS

Ideally a guided role for the primary carer should be central to therapeutic intervention with the sexually abused child. In this way the professional sessions will be enhanced with the prospect of an increasing ability to move forward more quickly. Unfortunately, in practice, we are constantly faced with great difficulty in enlisting this level of involvement by the carers. One reason for this is that so many of the families with which we are involved present with a complex range of problems, further complicated by disclosures of sexual abuse. We do not suggest that such family circumstances cause sexual abuse, but the existence of pre-conditions and opportunities for abuse must be recognised and addressed.

Regardless of the level of involvement in the child’s recovery, we offer parents/carers a service in their own right. In many cases this may well be advice/guidance or an educational role with regard to how to manage the aftermath of disclosure. Very often, with the best possible intentions, parents will over protect or over compensate, thereby creating further difficulties. In other instances the abuse might well be discussed on a regular basis in the presence of the child. Issues such as these will be addressed with parents directly in individual sessions and through the provision of relevant literature.

A mother of a child who had been raped reacted in a way that was compounding the trauma for her child. It was only on receiving counselling herself that she disclosed her own abusive experiences. Another mother whom we worked with showed more trauma than her teenage daughter did. The daughter was dealing well with her abuse but the mother had to be helped to overcome her grief and loss before she could support her daughter.

As previously mentioned, the team place great importance on working with other key professionals who are involved with the welfare of the child. A good example of this in practice is our liaison with the Criminal Justice System. From the outset we keep the Police Care Unit informed of our involvement. We also respond positively to requests for Victim Impact Reports, which will inform the Court prior to sentencing procedures. We provide similar reports in cases where applications for criminal compensation are being prepared.

Managing cases in this way improves the prospects of delivering the best possible service to the families with which we are involved. Given the stressful nature of the work, the issue of the individual workers health is also addressed. Sharing responsibilities in this way greatly reduces the risk of becoming overwhelmed to the extent that our intervention will have a negative impact.

The reader will be aware that child sexual abuse is a tremendously complex issue, cutting across law enforcement, child protection, mental health and judicial systems. In our therapeutic work with children there are a number of dilemmas, which we encounter on a regular basis. A number of these are looked at below.

Confidentiality and Protection Before Therapy
At the beginning of the therapeutic process the worker explains very clearly to the child and their carers that what the child shares in therapy is confidential, with the exceptions that if the child discloses ongoing abuse or the intention to self-harm, confidentiality must be broken in order to protect the child. Protection before therapy is crucial to recovery as a child exposed to on-going abuse, pressure from family members or the threat of further abuse will be unlikely to fully engage in therapy.
The team members are very clear that they cannot carry out investigative work and the child is referred back to the Family and Child Care Team for follow up. This can be difficult in that it causes a disruption to the recovery process. The team works closely with the Trust Child Protection Teams and will assume an advocacy role for the child if necessary.
The other dilemma that faces the team is that ‘rules of disclosure’ can demand that therapeutic records are made available to the Court, which may jeopardise the central trust relationship developed with the child. The team will oppose all applications for disclosure of our records within the Court system. Close links have been developed with the local court and issues are shared with the newly established Child Witnesses Support Team who have adopted an advocacy role for children within the judiciary system

Pre-trial Therapy
The team is aware of ongoing debate around this issue. Concern has been expressed that child witnesses may be denied therapy pending the outcome of a criminal trial for fear that their evidence could be contaminated and the prosecution lost. This is in direct conflict with ensuring that child victims are able to have immediate and effective treatment regardless of other interests to assist their recovery as soon as possible. The delay in the court process can exceed two years or more.

It must also be remembered, however, that while many victims express the wish to see their abuser convicted and punished, everyone has an interest in ensuring that those accused receive a fair trial.
The team recognises the importance of ensuring, wherever possible, that children who receive pre-trial therapy are regarded as witnesses who are able to give reliable testimony. For this reason we have debated at length the difficulties associated with the provision of pretrial therapy and contributed to a working party within the NSPCC to develop a ‘Good Practice Guidance’ for pre-trial therapy for child witnesses. This Guidance is currently in draft form.

The Unstable Child
Currently, a sizeable proportion of our work involves dealing with teenagers who are engaging in anti-social, offending and self-destructive behaviours. This can pose something of a dilemma when all therapeutic remedies have been exhausted. On occasions the team may suggest specialist involvement by the psychiatric services, which invariably brings a negative response from the young person. This is an extremely difficult issue, which must be managed with the utmost sensitivity. The very real danger is that we will add to the traumagenic factor of stigmatisation or reinforce the frequently held view of victims that, ‘I am going crazy". The young person will be involved fully in discussing the possible need for a psychiatric assessment with choice again being the major factor.
Occasionally a situation will arise where self-destructive behaviours are so extreme that we must recognise the inappropriateness of our involvement at this stage. The protection issues arising will take precedence with the team maintaining a supportive link for the young person throughout the duration of the other services required. A full therapeutic role will be resumed when stability has been re-established and the young person is ready to move forward.
The issues and dilemmas outlined above are not exhaustive and continue to challenge us in our work with children and young people who have been referred to us. These dilemmas are presented from the point of view of the therapists. Failure to resolve them could well result in the children being further abused by the very system whose role it is to protect them.

The concept of power is one that may be particularly helpful when considering evaluation of our work with abused children and young people. Evaluation seeks to give children some power in this important area of their lives as it conveys to them the message that their wishes, views and feelings are important to us and can help us improve our practice and service delivery. Methods of evaluating our service include questionnaires and an interactive computer programme. In our experience the questionnaires are more popular with teenagers and young people while the younger age group generally opt for the computer programme ‘Viewpoint’. Views of parents, carers and the referring social workers are also sought through a questionnaire. The comments made by all of our service users (particularly the children) have proved very useful in helping us shape and improve our service.
The evaluation process is conducted independently of the general therapeutic programme, by another member of staff, thereby allowing the child the freedom to comment critically on the service provided. Recently a child stated that she was not given the opportunity to talk about her abuse despite the fact that she had graphically described her experiences, in her drawings and written material, over the previous year in therapy. This child’s need to give a verbal account of her abuse was met in the concluding stages of her involvement with the team.
Our Viewpoint Evaluation is currently being fed into a NSPCC National Evaluation Programme and as yet there is no feedback from this.

The way forward should be driven by a desire to make improvements to existing services and to develop new or alternative approaches. We are committed to both. Our immediate plans involve the development of groupwork services for children and their parents/carers. The service will be on offer both as a supplement to individual therapy and as an alternative treatment of choice. At the present time groupwork has commenced with a group of teenage girls who have already benefited from individual therapy. The groupwork is now in its sixth week and feedback has been extremely positive to date.
This paper does not set out to put forward a blueprint for use with child victims of sexual abuse, but to describe the team’s framework for intervention, which is based on a number of influences. We have been on a steep learning curve. This paper reflects the progress we have made to date and has identified other areas which require further development.

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