This paper describes a sexual abuse-specific treatment program for children that combines creative art therapy groups for the abused child with concurrent supportive, psychoeducational therapy groups for non-offending parents. This program, led by Northside Center for Child Development’s Project SAFE program, has been supported by a grant from the World Childhood Foundation affording the program the opportunity to explore promising practices for ‘treatment reluctant’ families affected by sexual abuse while providing services that are essentially barrier free. The children and their parents in this program often present with myriad additional environmental stressors and emotional issues including depression, anger, denial, anxiety, guilt and diminished self-esteem.
Values Informing the Creative Arts Therapy Sexual Abuse Treatment
Despite an abundance of literature, increasing knowledge about the pervasiveness of sexual abuse and the frequency of sexual abuse referrals to community mental health clinics, there is no consensus on a single best treatment approach to effectively address complex impact of sexual abuse on children (Smith, 2008; Saywitz, Mannarino, Berliner, & Cohen, 2000). Although evidence is growing that trauma-focused cognitive behavioral therapies (TF-CBT) may be the most effective treatment intervention for treating depression, anxiety and behavior problems in these children and adolescents, not all children who have been sexually abused present with these specific symptoms nor meet DSM criteria for PTSD and trauma-specific treatment. In addition, treatment-outcome studies for sexual abuse demonstrating promising results for short-term CBT interventions “have focused primarily on less complicated diagnostic pictures and higher functioning families…[and] studies indicate that a continuum of approaches is necessary to meet the treatment needs of multi-problem cases who are not the children usually (Saywitz, et al, 2000, p. 1043).” Most importantly TF-CBT interventions are often compared in controlled studies to “nondirective supportive therapy (NST)” (Cohen, Deblinger, & Mannarino, 2004) — leaving a wide range of treatment possibilities between these two ends of the treatment continuum. There is acknowledgement in the field that child sexual abuse victims are a heterogeneous group and that an array of interventions needs to be considered and researched to best serve this diverse population. (Saywitz, et al, 2000) “To accommodate the different levels of care dictated by these different groups, a continuum of interventions is necessary, ranging from psychoeducation, to short-term abuse-focused CBTs with parental involvement, to more comprehensive long-term treatment plans for multi-problem cases (p. 1047).”
Impetus for our Creative Art therapy model evolved from the agency’s examination our use of art therapy with many types of children including those sexually abused along with individual and family therapy. We were particularly seeking a clinical model to reach children having difficulty expressing the abuse in words. Outreach when starting this program confirmed that very few agencies in the metropolitan region offered distinct programs for treating sexual abuse and none were found to offer treatment via group art therapy. In addition, our interactions with mental health workers as part of our referral process and research indicated that many clinicians reported feeling ill-prepared to effectively address the sexual abuse sequelae in individual treatment (Kolko, et al. 2009). Furthermore, those agencies that did specialize in sexual abuse treatment often had restrictions (requirements for attendance, specific symptom presentation, diagnosis, catchment area and/or insurance reimbursement) that made participation difficult or unappealing to more treatment reluctant families ‑‑‑families we might identify as at highest risk for abuse re-victimization.
Our model strives to improve how our clients feel about themselves in relation to others, with the abuse experience being an event that happened to them, not one that defines them. Our approach is values-centered treatment attempting to find the middle ground between highly specific interventions designed to reduce PTSD and depressive symptoms and client-directed psychodynamic therapies designed to validate and support. The groups integrate components of well-known evidence-based practices (i.e. TF-CBT) with the creative arts therapies, concurrent caregiver support groups, and a flexible, barrier-free program structure. Given this approach along with the lack of concrete barriers afforded us by World Childhood Foundation’s grants, we have been able to serve children and families who may have previously fallen through the cracks or who presented with ambivalence to treatment through extensive, ongoing outreach throughout the group cycle, concrete support for families to facilitate attendance and an atmosphere that promotes acceptance of the child and family. Referrals have primarily come from New York Children’s Services and other community programs as well as from programs within our agency.
The child art therapy groups have a 23-week group cycle serving about 25 children per year in small, gender and age-based groups. Art therapy is used because the traumatic experience of abuse can be difficult to articulate using purely verbal means and children naturally communicate through play and art. The goal of our group interventions is to help the children make meaning of their experiences so that they can regain a sense of control, improve self-esteem, decrease high-risk behaviors, and know that they are not alone in their experiences. This 23-week cycle allows children to begin to develop trust for those in their group in order to feel safe enough to express in art or in words the myriad issues associated with sexual abuse victimization. Psychoeducation in the group includes learning about body safety, managing anger and impulsivity, and understanding personal boundaries.
The parallel parent group offers the unique support of knowing they are not alone, helping them accept the validity of their child’s experience, and allowing them to safely expose feelings of depression, confusion, guilt, anger and stigma over this event which impacts the whole family. Research suggests that the most overriding factor in the success or failure of treatment for a sexually abused child is that the parent believes the abuse occurred.
Parents and caregivers are critically important to the healing process and not simply ancillary to the children’s art group therapy. Their recognition of the child’s experience and support for the child is a powerful ingredient in the child’s becoming more open as they are validated by their parent leading to better prospects for recovery. In addition, and not infrequently, parents in the group reveal their own experience of abuse as a child with its damage to their emotional wellbeing. The parent groups, led by a social worker, facilitate parental working through the range of emotions brought up by the child’s abuse, (and their own, if applicable) while helping them learn positive coping skills to address the impact of the abuse on the child and family. Ongoing psychoeducation in the group includes discussions with parents around the range of sexually abusive experiences, common symptoms associated with child sexual abuse and the creation of safety plans for their family to prevent re-victimization. In addition, unlike many group therapy protocols, parents in the group are encouraged to continue their support network outside the group so they will have an ongoing network of support after the group ends.
Each child/parent group cycle has at least one session in which the children and parents come together for a multi-family art therapy group to enhance their relationship going forward. To further facilitate the healing process, a recreational event for all the families is the final session helping families celebrate achievements, creating a sense of community among members, and increasing each family’s circle of support.
Our Values-Centered Approach
Value 1: We respect a client’s readiness for treatment. Meeting clients as far as they can go means just that. It is our value that the group process will deal with a range of experiences including but not limited to depression, denial and anger and offer a healing supportive process of acceptance of abuse as the child becomes able to express their experience in art or even in words.
Value 2: We engage from a nurturing position within a flexible holding environment. The clinical team members display nurturance with one another and with family members in a nonphysical yet emotional way.
Value 3: The experience of community support enhances self-awareness and interpersonal communication. The social identity within the group and community concept becomes a cyclic rather than linear experience. The sense of community as they are neighbors and community members is stressed as well as that they are a community of survivors.
Value 4: Cultural and value acceptance means accepting clients’ values around gender, power, and identity. The parents’ group membership consists primarily of mothers coming from marginalized groups in the larger society. They are encouraged to discuss their values and social identity as these socio-cultural factors are key components in their experiences. In the children’s group, these issues are explored to match the developmental needs of the child. Acculturation issues, in particular children not subscribing to parents’ more traditional conceptualizations of race and ethnicity, are invited into the discussion. The art therapist takes a firm, clear position regarding child-adult roles and responsibilities while remaining culturally sensitive.
Parents/caregivers have reported encouraging changes in the behavior of their children—indicating that the children have enjoyed improved relationships with others. We have also noted significant changes in the parent child relationship with many parents reporting feeling more positively about their children. The children themselves have indicated feelings of relief in knowing that they are not alone in their abuse experience and have frequently identified group members as their closest friends.
In order to seek a more objective evaluation, after several years of using behavioral check-lists and PTSD scales the team decided that we needed an evaluation tool that aligned more closely to our intended outcomes. The Tennessee Self-Concept Scale, designed to “examine the self-view a person brings to specific areas of experience,” including physical, moral, personal, family, social, and academic arenas, was selected. Of particular interest to our team were the validity scores which are sensitive to an individual’s efforts to “fake” being good, a common behavioral trait in sexually abused children who try to manage and control the responses and/or affection they receive from others to avoid being hurt again.
The children (average 11 years old) completing this scale to date are 88% female, 36% African American, 48% Hispanic/Latino, 8% multi-racial and 8% other. They range from 1st to 10th graders. Given the recent implementation of this tool and the small number of clients tested to date, the results below should be viewed as a very preliminary finding. On average, clients had higher Social Self-Concept scores at posttest: 61% had higher scores with the average posttest score being 51T (vs. 48T pretest), p <.05. The values improved so that the average score is about the same as for the U.S. norm group (50T average score) on this scale. (Individuals with scores of 60T and above are usually viewed by both themselves and others as being friendly, easy to be with, and extroverted. A score of 70T or above may reflect grandiosity or an inflated self-opinion. Scores of 40T and below are related to a perceived lack of social skill.) These results are promising but preliminary. We continue to provide what we believe is effective treatment for sexually abused children while also seeking objective methods to assess our treatment model.
Adrienne Williams Myers, LCSW, is Chief of Preventive Services; Jean Holland, LCSW, is Clinic Director; Drena Fagen, LCAT, is Art Therapist; Alexis Howard, LCSW, is Social Work Consultant; Sandra Scott, PhD, is Director of Research and Evaluation; and Thelma Dye, PhD, is Executive Director and CEO of Northside Center for Child Development.