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Therapeutic Responses to Child Sexual Abuse

ACCESS TO SUPPORT AND THERAPEUTIC SERVICES

A recent review identified 49 studies from Australia and the US that report data on therapy referral, engagement and completion following a disclosure of sexual abuse to police or child protection authorities. This review found that less than half of children with suspected abuse seen by authorities received a referral to therapy, although most with substantiated abuse did. Of all victims that were referred to some sort of therapy, only 60% followed through with therapeutic treatment. Of those that did access therapeutic services, 80% were engaged (Herbert, 2021a).

A pooled rate of completion of therapy across studies with community samples was 59%, ranging from 31% to 87% (Herbert, 2021a). Children who experienced more frequent and severe abuse were more likely to complete treatment programs. Children were also found to be more likely to complete treatment if the offender was a family member. If there was a delay in commencing therapy after referral, for any reason, the treatment was less likely to be completed. Higher levels of parental involvement in the therapy, as well as parental encouragement to access support services, resulted in higher levels of completion (Herbert, 2021b).

Research conducted by Gekoski and colleagues (2020) in England and Wales found that 73% of child sexual assault survivors (as adults) reported never having accessed any form of support or treatment. Of the 27% of survivors that had accessed support, almost all of them (98%) had accessed recovery support with the number having accessed healthcare or justice support being significantly less. The most common support service accessed was a counsellor specialised in child sexual abuse. The study also found that the time taken to access support services after the abuse had taken place averaged 19 years, with a range from 1 to 58 years. Those survivors who had accessed support services reported that there were often long waiting lists that delayed access, however there was a consensus that support services, for both children and adult victims of sexual abuse, are much easier to access now than they have been in the past. Participants also stated that personal barriers, such as not feeling comfortable talking about the abuse or not feeling that they needed any form of support or treatment, were the biggest obstructions to accessing support services (Gekoski et al., 2020).

Most (87%) victims of “recorded” child sexual abuse (i.e., recorded via images or video) in a survey by the Canadian Center for Child Protection reported having accessed therapy at some stage. Almost all (95%) of these survivors had received therapy as an adult; with some only receiving treatment as an adult. Most (64%) of those who delayed receiving therapy indicated that they were not ready to discuss the abuse and/or did not realise they needed help with dealing with their experience. A further 34% had problems with accessing or finding a suitable therapist (Canadian Center for Child Protection, 2017).

THERAPEUTIC RESPONSES TO TRAUMA

Variations of cognitive behavioural therapies, including Trauma-Focused Cognitive Behavioural Therapy (TF-CBT), are the most used treatment models for children and adults with trauma symptoms, as they have greater empirical support than other treatment methods (Black, Woodworth, Tremblay, & Carpenter, 2012). The evidence base for TF-CBT is broad, with randomised trials supporting its success in improving symptoms among children and adolescents who have experienced sexual abuse, domestic violence, traumatic grief, natural disasters, and complex trauma (Dauber, Lotsos & Pulido, 2015).

A qualitative review of trauma-focused therapies for children and adolescents reveals five common therapeutic techniques: psychoeducation, coping skills, creating a trauma narrative, cognitive restructuring, and creating a post-treatment plan (Black et al., 2012).

The Complex Trauma Workgroup of the National Traumatic Stress Network in the US has identified six core components of complex trauma interventions for children and adolescents, which should follow a phase-based approach. These include: safety; self-regulation; self-reflective information processing; trauma experience reintegration; relational engagement; and positive affect enhancement (Cook, Spinazzola, Ford et al., 2005).

An examination of the effectiveness of three widely disseminated trauma treatments – Attachment Self-Regulation and Competency (ARC) framework; Child-Parent Psychotherapy; and Trauma-Focused CBT – was conducted to compare the effects of each treatment model on maltreated children’s functioning. The results of this study, conducted with 842 children accessing one of the three trauma treatments, showed that treatment was associated with significant improvements in child behaviour problems, PTSD symptoms, strengths and needs. Results were found to differ by treatment model, however, with the best outcomes seen for children receiving ARC and TF-CBT (Bartlett, Griffin, Spinazzola et al., 2018).

Play therapy has been recognised as providing children and adolescents with developmentally appropriate means of improving affect regulation, self-efficacy, problem solving and formation of trust. Integrating play therapy with cognitive-behavioural methods has been recommended for treating children with trauma symptoms (Green & Myrick, 2014).

A review of models for treating complex trauma in children and adolescents found  that emerging models tend to have longer treatment lengths (e.g., 20-52 sessions) than models for PTSD due to increased severity of symptoms. Additionally, caregiver involvement has been found to be integral among most complex trauma treatment models, especially for children; and the enhancement of self-regulation and anxiety tolerance skills are common to all approaches. Most treatment models reviewed included a wide range of interventions drawing from a range of theories and therapies, including attachment theory, CBT, trauma theory, and family and exosystemic theory (Lawson & Quinn, 2013).

Reviews of 10 published studies focused on models for treating adults with complex trauma resulting from childhood physical and/or sexual abuse have found moderate to large effect sizes for all 10 studies for treatment groups compared with control groups with regard to improved emotional regulation capacity and social and interpersonal skills. Studies focusing on both stabilisation/skill development and trauma memory processing have also been found to be more effective than studies that emphasise either skills development or memory processing alone (Lawson, 2017; Cloitre, Courtios, Ford et al., 2012).

ANIMAL ASSISTED THERAPY

Animal-Assisted Therapy (AAT) is an umbrella term for diverse therapeutic approaches used with people of all ages in which an animal is an integral part of the treatment process (Zilcha-Mano, Mikulincer & Shaver, 2011).

A systematic review of studies evaluating animal-assisted interventions for trauma found just 10 studies, with seven of these examining post-traumatic stress outcomes in child and adolescent survivors of physical or sexual abuse, and the remaining three in military veterans (O’Haire, Guérin & Kirkham, 2015). While this review showed a generally low level of methodological rigour used across studies, it did find short-term subjective benefits for animal-assisted therapy, including decreased depression, PTSD symptoms, and anxiety (O’Haire et al., 2015).

A meta-analysis of animal-assisted psychotherapeutic interventions for trauma found eight studies which had quantitatively assessed program impact. The majority (six of the eight studies) involved group interventions, and three of the eight studies were evaluations of the same Australian equine-therapy progam. Overall, meta-analysis results showed that animal-assisted psychotherapy is effective in reducing trauma symptoms (Germain, Wilkie, Milbourne & Theule, 2018).

One of the more methodologically rigorous studies, conducted through a Child Advocacy Center in the United States, involved the evaluation of group interventions for child victims of sexual assault, with participants assigned (according to location) to either a group intervention, group intervention with therapy dog visitation, or a group intervention with therapy dog visitation plus the integration of narrative stories involving the dogs into group sessions (Deitz, Davis & Pennings, 2012). Results indicated that children in the groups that included therapy dogs showed significant decreases in trauma symptoms, including anxiety, depression, anger, PTSD, dissociation and sexual concerns, and that children who participated in the group with therapeutic stories showed significantly more change than the other groups. The results of this research highlight the additional benefits of integrating support animals into the therapeutic process above and beyond the benefits provided by the mere presence of a support dog (Deitz et al., 2012).

A recent clinical trial examining animal-assisted therapy (AAT) as an adjunct to Trauma-Focused CBT for abused youth with PTSD, meanwhile, found that the inclusion of AAT did not enhance improvement of PTSD symptom severity. In fact, this study found through qualitative methods that AAT may have attenuated improvement in many cases, through increased avoidance of (particularly uncomfortable) therapeutic activities (Allen et al., 2021).

Research has suggested that the introduction of animals into therapy may impact positively on therapeutic engagement. Evaluation of an Australian AAT based program found that the completion rate of the program was 90%, despite the presence of several acknowledged “risk” factors for attrition, including high symptom severity, male gender and ethnicity (Signal, Taylor, Prentice, McDade & Burke, 2017).

REFERENCES

Allen, B., Shenk, C.E., Dreschel, N.E., Wang, M., Bucher, A.M., Desir, M.P., Chen, M.J., & Grabowski, S.R. (2021). Integrating animal-assisted therapy into TF-CBT for abused youth with PTSD: A randomized controlled feasibility trial. Child Maltreatment, DOI: 10.1177/1077559520988790.

Bartlett, J.D., Griffin, J.L., Spinazzola, J., Goldman Fraser, J., Norona, C.R., Bodian, R., et al. (2018). The impact of a statewide trauma-informed care initiative in child welfare on the well-being of children and youth with complex trauma. Children and Youth Services Review, 84, 110-117.

Black, P.J., Woodworth, M., Tremblay, M., & Carpenter, T. (2012). A review of trauma-informed treatment for adolescents. Canadian Psychology, 53(3), 192-203.

Canadian Centre for Child Protection. (2017). Survivors’ survey: full report 2017. Canadian Centre for Child Protection.

Cloitre, M., Courtois, C.A., Ford, J.D., Green, B.L., Alexander, P., Briere, J., et al. (2012). The ISTSS expert consensus treatment guidelines for complex PTSD in adults. Retrieved from http://www. istss.org/treating-trauma/istss-complex-ptsd-treatment-guidelines.aspx

Cook, A., Spinazzola, J., Ford, J., Lanktree, C., Blaustein, M., et al. (2005). Complex trauma in children and adolescents. Psychiatric Annals, 35(5), 390-398.

Dauber, S., Lotsos, K., & Pulido, M.L. (2015). Treatment of complex trauma on the front lines: A preliminary look at child outcomes in an agency sample. Child and Adolescent Social Work, 32, 529-543.

Dietz, T.J., Davis, D., & Pennings, J. (2012). Evaluating Animal-assisted Therapy in group treatment for child sexual abuse. Journal of Child Sexual Abuse, 21(6), 665-683. DOI: 10.1080/10538712.2012.726700.

Gekoski, A., McSweeney, T., Broome, S., Adler, J., Jenkins, S., & Georgiou, D. (2020). Support services for victims and survivors of child sexual abuse. Independent Inquiry into Child Sexual Abuse.

Germain, S.M., Wilkie, K.D., Milbourne, V.M.K., & Theule, J. (2018). Animal-assisted Psychotherapy and Trauma: A Meta-analysis. Anthrozoös, 31(2), 141-164. DOI: 10.1080/08927936.2018.1434044.

Green, E.J., & Myrick, A.C. (2014). Treating complex trauma in adolescents: A phase-based, integrative approach for play therapists. International Journal of Play Therapy, 23(3), 131-145.

Herbert, J. (2021a). Rates of therapy use following a disclosure of child sexual abuse. Australian Institute of Family Studies.

Herbert, J. (2021b). Factors influencing therapy use following a disclosure of child sexual abuse. Australian Institute of Family Studies.

Lawson, D.M. (2017). Treating adults with complex trauma: An evidence-based case study. Journal of Counselling and Development, 95, DOI:  10.1002/jcad.12143.

Lawson, D.M., & Quinn, J. (2013). Complex trauma in children and adolescents: Evidence-based practice in clinical settings. Journal of Clinical Psychology, 69(5), 497-509.

O’Haire, M.E., Guérin, N.A., & Kirkham, A.C. Animal-assisted intervention for trauma: A systematic literature review. Frontiers in Psychology, 6, 1-13.

Signal, T., Taylor, N., Prentice, K., McDade, M., & Burke, K. J. (2017). Going to the dogs: A quasi-experimental assessment of animal assisted therapy for children who have experienced abuse. Applied Developmental Science, 21(2), 81–93.

Zilcha-Mano, S., Mikulincer, M., & Shaver, P.R. (2011). Pet in the therapy room: An attachment perspective on Animal-Assisted Therapy. Attachment & Human Development, 13(6), 541-561. DOI: 10.1080/14616734.2011.608987

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