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Intervention models. Working rules in cases of sexual abuse from a psychosocial perspective

G. Fischer and P. Riedesser (2000) in their work Psychotraumatology Handbook present trauma as a definition of traumatic experience, thus “psychological traumatisation is defined as a vital experience of discrepancy between threatening situational factors and the individual’s possibilities of mastery, a trauma accompanied by feelings of helplessness and helpless abandonment, which thus produces a lasting disruption of the understanding of self and the world”. The word trauma can refer to a physical injury caused by external agents or a mental injury caused by a frightening experience.

James (1989) defines trauma as an uncontrolled experience that psychologically affects the victim inducing feelings of helplessness, vulnerability, loss of safety and control. Intense fear in combination with loss of power are the basic ingredients of a traumatic experience in the psychological sense.

Children can be traumatised by unexperienced adults by the situations they sometimes put them in, for example being accidentally separated from their mother in a shop or on the street or being frightened by an older sister or brother. Stories of crime on TV or in the newspapers can cause traumatic experiences.

The effects of the maltreatment on the child are the effects of a traumatic event. Starting from the psychoanalytic understanding of the concept of trauma Laplanche and Pontalis (1994, p.444) circumscribe it as “the event in the life of the subject which is defining in its intensity, the inability of the subject to respond adequately to it, the disturbance and the lasting pathogenic effects it causes in the psychological organization, in economic terms, trauma is characterized by an influx of excitations which is excessive in relation to the subject’s tolerance and capacity to control and elaborate them psychologically”.

  • In working with abused children there are several theoretical guidelines that provide useful insights:

Development theories deal with the following issues:

  • Normal child development;
  • The effects of attachment and loss on children;
  • The impact of normal and abnormal life experiences.

Interhuman theories include:

  • How important relationships influence the child’s identity, perceptions, beliefs and interactions, such as object relations theories, personal psychology and ego psychology;
  • The role of the therapeutic relationship and the use of affective countertransference.

Cognitive behavioral theories study:

  • The relationship between feelings and behaviour and how changes are made;
  • How negative feelings are associated with perceptions of child abuse;
  • How the developmental sequence of phenomena such as perception, motivation and affect influence the child’s power to reorganise their cognition.

Systemic theories deal with:

  • The importance of the family and the society in which the child lives;
  • Correlations and their impact on the child;
  • Practical and useful interventions in the family, school and community.

Abuse and victimization theories study:

  • The effects of physical and sexual abuse on children;
  • Vulnerability and resilience;
  • Long-term effects of abuse and neglect.

Psychotherapeutic ways of intervention:

  • Individual psychotherapy;
  • Group psychotherapy;
  • Family psychotherapy.

The literature particularly recommends psychodrama, therapeutic fairy tales and art therapy as techniques for the psychological recovery of children who have suffered some form of abuse. The therapeutic approach requires good coordination between all those involved. Whatever the intervention technique, it will be long-term and will target:

  • Developing defence mechanisms;
  • Detachment from trauma;
  • Instilling confidence in an appropriate resolution.

Models of therapeutic intervention in cases of child abuse

The treatment of psycho-traumatic disorders requires, as outlined in the literature, the integration of therapeutic methodology. The rules to be followed in the therapy of the traumatised child as well as the core areas and themes of therapy allow for integrative approaches. The current trend is to move from intuitive and pragmatic work to the elaboration of principles that play a role in creating “a conceptual framework that synthesises the best elements belonging to at least two therapeutic approaches” (I.Dafinoiu, 1999), stressing that “in psychotherapy, integration is a form of synthesis in which at least two theories are included, with the hope of obtaining results superior to those of using the initial theories separately”.

Cognitive-behavioural therapies

Cognitive-behavioural therapies aim to identify the factors that trigger and maintain the subject’s perceived disturbances, the ultimate goal being to find possibilities for change and self-suggestion. The techniques are varied:

  • Systematic exposure and desensitization;
  • Cognitive restructuring;
  • Anxiety control through: thought stopping, relaxation, breathing control techniques.

A metaphor allows us to understand the interest in exposure technique. A person who can’t stand the idea of seeing a horror film will get used to the film if they agree to watch it ten times. On the contrary he will be afraid if he continues to avoid it. The same can happen with trauma victims who avoid being confronted with things that might remind them of the traumatic event, such as anxious thoughts, images, sensations, situations.

This exposure takes place in a safe therapeutic setting which is necessary whatever technique is used. If the patient is very anxious we help them to cope with the anxiety through relaxation exercises that will help to lower the tension, all to maintain the image of the scene experienced. Each session is repeated until it stops causing anxiety. It generally takes 10 exposure sessions to eliminate a symptom. The patient can continue exposure outside the psychotherapy sessions if they have been recorded.

Cognitive reconstruction is based on the idea that trauma has created a situation of loss of control leading to a disruption of the general belief in the world, in others and in oneself: the world that was predictable has become unpredictable, security has turned into insecurity. Cognitive reconstruction consists of helping the victim to modify his negative thoughts and reformulate them in a positive way. The answer to these questions has a great influence on the client’s emotional level and behaviour. The therapist must help the patient to focus on his or her environment and assess the level of danger in a realistic way. Therapy can draw the patient’s attention to the thought processes that he or she uses in problem situations and help him or her to notice the processes of generalisation (all or nothing), inference or personalisation. The therapist teaches him to focus on his internal discourse to observe how he relates to himself. He also teaches him to notice negative, blaming or irrational dialogue. The patient has to discover for himself what kind of process he has engaged in at a particular moment: if he finds his thinking negative he will learn to counterbalance it with a hypothesis or a realistic statement every time he thinks about the trauma and substitute it with a rational, fair, valuing discourse. For each negative thought the therapist encourages him to measure his probability of survival and to control self-criticism and self-deprecation.

While exposure is used for the patient to confront anxiety and observe, stress management techniques are aimed at learning to control anxiety. They are used when anxiety disrupts the individual’s daily functioning. They are used when anxiety disrupts an individual’s daily functioning. They are also used to complement the action of other techniques, when certain psycho-traumatic symptoms are in the foreground or to improve social and relational skills. Stress management consists of a set of simple techniques and measures aimed at controlling the reaction to stress.

The main purpose of this strategy is to teach the client to re-evaluate the situation rather than constantly referring to the traumatic experience: “How can I act like any other human being after this trauma?”. Often problems are formulated so vaguely that it is not easy to find a solution. The patient will be asked to clarify his/her problems one by one in the following way: define the problem, search for possible solutions, identify the advantages and disadvantages of each solution, choose a solution, analyse the result obtained. If the choice is not good, if it does not work, it is important to redefine the problem by integrating new unsolved aspects and to repeat the cycle until the optimal solution is found.

“These therapies are clearly effective when avoidant behaviours characteristic of post-traumatic stress are dominant, especially in adolescents,” Lopez points out.

Cognitive-behavioural therapies are very useful and convincing for patients who want objective results in reducing psycho-traumatic disorders by confronting the problem directly in a safe therapeutic setting.

The “DESA” model – a way of therapeutic intervention

The DESA model of therapeutic intervention is the modality of therapeutic intervention in cases of child abuse used by Swedish therapists at the Boys’ Clinic in Stockholm and is based on cognitive behavioural therapies. It is also used by psychologists in the Counselling Centres of Save the Children Romania.

DESA model:

D – description

E – expression 

S – say “NO” 

A – acceptance

This model synthesises certain core areas and therapy themes that can serve as steps in the therapeutic approach. The four steps of the model are not strictly delimited, in many cases they can be different aspects of the same problem.

The model should be understood as different dimensions of therapy, processes that have different centres of focus and which may interfere sequentially or concurrently.

  • Description of abuse

Describing abuse is the way to make ‘reality real’. At this stage children use different modes of expression depending on their age and mood. For some children language is the best way, expressing in words the abusive acts they have been subjected to. Others prefer to show what they have experienced through play, especially young children. For some, however, the best ways of expressing abuse are drawings and/or the use of anatomical dolls. For some children it may be impossible to describe the abuse they have experienced regardless of the means of expression available to them. Secrets, forgetting and dissociation emerge as themes for therapy during this stage.

  • The secret

Secrets become an important therapeutic theme in cases of child abuse. Sometimes the child refuses to talk about the abuse because he or she has been told that it is a secret that must remain between him or herself and the abuser, or in the family. That’s why it’s important to explain to children what ‘good secrets’ and ‘bad secrets’ mean.

One of the biggest obstacles in getting children to describe what they have been through is that the abuse has in most cases been kept secret and associated with shame and threats.

E.g.: “Diana kept secret the abuse she was subjected to by her father for 12 years. He threatened her that if she said anything then he would abuse her sisters too. From age 6 to 18 she kept what was going on between her and her father a secret. It was all revealed that he was actually abusing her sisters at the same time.”

“Irina kept her stepfather’s abuse a secret for three years until her grandmother noticed certain changes in her disposition. Threats of beatings and killing her mother prompted her to keep the secret.”

A story about good and bad secrets can help your child. Good secrets are tempting, it’s even good to surprise mum or a loved one by buying them a present and keeping it a secret until their birthday. But bad secrets can give you nightmares, scare you and worry you. Children shouldn’t keep secrets like that. They must be told to an adult, even if they have promised not to tell anyone, otherwise they will be hard to forget and the fear will not go away.

There is a possibility that some children may not feel ashamed or guilty, they may simply decide they have nothing to talk about. In this case we should not insist that they talk to us. The therapist in such cases can tell them what they know or what has been reported to them from police investigations or other sources.

  • Expressing feelings

The therapist works hard to help children describe their feelings associated with the abuse. This is one of the major steps in therapy. At this stage a variety of materials are used to help children express their feelings. The use of stories in which certain animals can be symbols of good and evil, danger and safety, fear and courage, trust and distrust, plays a major role in helping children to identify their own feelings and experiences.

  • Boundaries

Anyone who has had their spatial, somatic and emotional territory violated through sexual abuse is at risk of violating other people’s boundaries. They need help in identifying and expressing emotions related to “wanting” and “not wanting”, “accepting” and “denying”, “putting oneself in the other person’s place”, situating boundaries in relation to one’s own body, but also in relation to others.

  • Acceptance

Ultimately these children must learn to move on with their lives, to avoid falling into the identity of victim, to reconcile what happened to them and leave it in the past, to let go of the idea that the past can be remade or denied and leave it in the past, to let go of the idea that the past can be remade or denied and accept that full justice can never be achieved. It is not certain that sexually abused children will ever be able to accept their fate. Many will carry anger, fear, and especially shame in their hearts for a long time to come.

The idea of acceptance and reconciliation is an experience of faith that there is a way out of helplessness. For this these children need a lot of support from those around them to be able to accept themselves as normal despite the unusual and abnormal experiences they have been through.

E.g.: “Oana, a girl who was sexually abused told me that she is not like the other girls anymore, that she is different and that she is ashamed to go and play with them. When I asked her how she is different, she told me that she feels dirty towards them and that she can’t play anymore.”

It is important that these children who have been sexually abused are able to resume some of the activities that children of their own age do. There is a risk that not only the child, but also those around them will be left with the idea that the abuse is the cause of all their problems, with the abuse being taken as an excuse. Acceptance and reconciliation are equally difficult and necessary for the adults who are part of the abused child’s life.

An important part of acceptance is that things could have been different. Carrying the longing for a father or the pain of never having had one is a therapy team. Children who have been abused by their biological father miss a “good” father and also wish that their mother or someone else had been able to understand and intervene for them. Grief and longing become important themes in this part of treatment, and of course hope.

  • Gestalt therapy

By providing a warm, conversational setting, the Gestalt therapist can bring specific help to victims of sexual assault. The anchor point of gestalt work is listening to the body and emotions. Here we briefly describe the extent to which this approach can be of practical help in dealing with peri-traumatic dissociation.

Dissociation is a mechanism frequently found in people who have suffered trauma, especially sexual assault. It translates into flashback memories, the impression of not really being there, the impression of watching the scene from outside the body. In sexual assault it is the body that suffers the brutal sexuality imposed by violence. From this point of view only the body shell is touched, i.e. the landmarks we have built as individuals. During the manifestation of this dissociation mechanism it is impossible for the person to integrate this event into his or her life. Before this event can be integrated, we believe that it is essential for the person to re-appropriate their body. Concretely, this is done by the patient and therapist paying attention to the body sensations and emotions triggered. It is obvious that this attention is not done through tactile touch. It is a verbal appropriation aimed not only at exploring his body, but also at the possibility of relaxation. This relaxation acts as if it contains anxieties, because these anxieties inevitably operate as the patient begins to pay attention to his body, i.e. to return to his reality.

In terms of dialogue, voice and words allow the patient to control their anxieties and thus to resort less to the dissociation mechanism. He can feel as new both literally and figuratively. By taking possession of his body as a place of residence and pleasure, the person rebuilds landmarks that allow him to reconnect with the outside world. It is a process that takes time. Time to establish trust between patient and therapist and time to gain confidence in tapping into one’s own resources.

  • EMDR Eye Movement Desensitization and Reprocessing

Fischer (2000) presents this method as an interesting union between process-oriented and active interventions. Already in the name it expresses the synthesis between behavioural and psychodynamic therapy.

EMDR is a technique that consists of exposing the victim, thoughts, emotions, bodily sensations that accompany the trauma. It is similar to the techniques we have outlined above. Eye movements are meant to accelerate desensitisation and deal with information stuck in the brain, that information that is metaphorically responsible for the repetition of thoughts, images, nightmares and avoidances that tend to control them. This technique also allows a cognitive reconstruction of negative thoughts into positive thoughts. This widely tested method allows some therapists to approach treatment with a new tool that is well grounded in the victim’s lived reality.

G.Lopez believes that this technique is “very effective in children and adolescents in the aftermath of psychological trauma, especially when an intrusive syndrome is dominant.”

Dynamic psychotherapies

Psychoanalysis is a psychotherapeutic treatment based on the analysis of the relationship established between therapist and patient (transference). The patient re-enacts with his therapist old scenarios reactualised into present symptoms. It remains in the field of fantasy and non-event. It has no indications in emergencies, but can be used if the therapist agrees to treat present symptoms in relation to a recent traumatic event is satisfied if the victim does not want to cross over. For victims of old and repeated events the therapist must adapt a specific technique for neuroses i.e. the symptoms are attached to the avatars of personality structuring during childhood (oedipal period). The most common disorders presented by these victims are studied in a completely different register (narcissistic pathology, borderline). Transference is not neurotic, it is in fact a literal enactment. In this type of traumatic transference, the risk of sexual intercourse is significant and expected to be dramatic, even if the intercourse appears to be consensual. We need to be attentive to this issue and accept the use of technical adaptations necessary in this context: empathy, face-to-face discussions, verbal exchanges.

Systematic therapy includes the following theories:

  1. Involvement of family and society in the child’s life,
  2. Family interest and its impact on the child,
  3. Useful and practical interventions with family, school, community

Family and especially network therapies are useful for treating families as much as possible in the case of late detection of sexual abuse in the family. They postulate that there must be a concern not only for the victim, but equally for the family system and further socially, i.e. for all interventions that take part in the process triggered by disclosure. Under no circumstances should the perpetrator take part in sessions. For example, in order to help incestuous families break the communicational deadlock, the technique of amplifying the crisis following the discovery can be used by encouraging the family to submit to the criminal law and denounce the perpetrator. Conjunctively, to combat the confusion of the communication system that governs these families, their members are prompted to question their own traumatic history. This allows the family to supplement their confused communication system with shared emotion.

Family therapy allows the rules of family functioning to change. They are not indicated if the rape occurs in a person with no traumatic history. On the other hand, it is always very useful to be able to organise family meetings to inform the family of the consequences of rape on the victim and his or her entourage in order to avoid certain destructive conflicts often based on misunderstanding and the intention to help the victim.

Therapeutic goals for incestuous families:

    • Restoring structural boundaries;
  • Society/family;
  • Intergenerational;
  • Interpersonal;
  • Intrapsychic;
    • Correcting abuse of power;
  • Gender issues;
  • Conflict resolution processes;
  • Problem-solving processes;
  1. Facilitating external/internal control balance (depending on age);
  2. Restoring empathy (restructuring previous experiences of victimisation)
  3. Improving family communication;
  4. Decrease feelings of shame, increase self-esteem of all family members;
  5. De-exualisation and re-exualisation of relationships;
  6. Looking for other “symptoms”.

Ways to help families understand the post-traumatic stress of children who have experienced sexual abuse

The family may need help:

  • Accept and understand the child’s difficulties;
  • Express their feelings/emotions;
  • Accept their child’s feelings as normal;
  • To deal with the ‘duties’ that families have to fulfil in life;
  • To clarify distortions of thinking and misconceptions;
  • Dealing with family changes.

Helping brother, sister and parents

  • Encouraging ‘family problem solving’. This involves:
  • Relating from personal experience of living through a traumatic situation and its consequences;
  • Organising the family system where a child is permanently helpless or where a family member has died.

G.Lopez (2000) believes that all the methods used have their advantages in victim therapy if the person who uses them knows them well and has experience in treating victims. Therapeutic techniques are used less for scientific recognition than for the experience and training of therapists who can help victims in this way. Also G.Lopez (2000) insists on the need to have knowledge of victimology in order to guide victims correctly in the social and judicial services network, avoiding their overvictimisation and to maintain a safe therapeutic environment.

“The aim of all treatment for children who have suffered a trauma is to provoke a traumatic emotional externalisation, thus avoiding the perpetuation of the mnesic traces, conscious or unconscious, which manifest themselves in repetitive cognitions, avoidance behaviour, cognitive disorders, etc., characteristic of post-traumatic stress syndrome”, points out G. Lopez (2000).




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