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Sexual abuse and the use of play in psychotherapy

In recent years there has been a growing social awareness of the child sexual abuse and a greater interest of clinicians in the relevance, impact and treatment of this problem. At the same time, its traumatic impact on the child has been recognized, as well as its long-term consequences, which can persist into adulthood (Knell, 1998).

Although there may be common sequelae of abuse, the impact may manifest itself differently with each child. Symptoms that occur frequently in very young children include sleep disturbances, regression in toileting and other skills, expressions of anger and fear, depression, anxiety, and sexualized behaviors (Beitchman, Zucker, Hood, da Costa, & Akman, 1991; Browne and Finkelhor, 1986; Finkelhor, 1990; Green, 1993; Kendall- Tackett, Williams, & Finkelhor, 1993). The research also hypothesized a close connection between childhood sexual abuse and the Post-Traumatic Stress Disorder diagnosis.

Much of the available literature agrees that a certain period of treatment is required and recommends integration between individual, group and/or family treatment.

The Cognitive-Behavioral Play Therapy intervention reported in this article is taken from the work of Susan Knell and Christine D. Ruma Play Therapy with a Sexually Abused Child where the application of Cognitive-Behavioral Play Therapy (CBPT) is described with a child who has been sexually abused.

Background information

A 5-year-old girl was referred for psychotherapy following her revelation of sexual abuse. The maltreatment would have occurred two times, at the neighbor’s house. The man would show her his “privates” the first time in the bathroom and the second upstairs while his family was around the house. Since the disclosure, the girl had begun displaying several characteristic symptoms of sexually abused children: the need to urinate frequently and to go to the bathroom at school or on the school bus; anxiety and fear of being alone on one floor of the house, while other family members were on another level of the home. These symptoms appear to be related to the context in which she was abused and have generalized at home and at school.

Assessment with parents

During the initial appointment, girl’s mother was interviewed. Additionally, she was asked to complete the Child Behavior Checklist (CBCL; Achenbach, 1991). Although there were no clinical elevations, significant items were detected in the withdrawal, fear, regressions, not being able to distract from certain thoughts and school fear areas, with elevation of the Social Problems and Thinking Problems scales.

Treatment

Cognitive-Behavioral Play Therapy was used for a total of 13 sessions over a 3½-month period.

The little girl was not included in the first session. Either one or both parents were seen for at least a portion of each session to discuss the child’s progress and to answer any questions. The entire family was included in two sessions. Several different play modalities were employed, including bibliotherapy, drawing techniques, puppet play and clay modeling. After the initial assessment appointment 12 sessions of Cognitive-Behavioral Play Therapy were conducted.

During the first part of the therapy the primary task was first to create a book of drawings about what happened with the neighbor and then to have the child share her story with the family, although she felt uncomfortable with describing the details of abuse and did not know what words to use to tell about it. Thanks to the introduction of the use of puppets, the little girl was able to disclose that the neighbor had touched her in her genital area and threatened her not to tell. Subsequently, the therapist engaged with the child in puppet play to better investigate possible cognitive distortions and maladaptive attributions relating to sexual abuse.

Following a 3-week gap, the parents reported that during this time the girl began to have nightmares as frequently as 4 to 5 times per week. The therapist therefore worked on cognitive restructuring through drawing.

Based on the decrease in symptoms, the lack of any apparent distorted perceptions related to the abuse, and the child’s ability to disclose, the therapist began to prepare for termination. After the child’s choice to model clay, the therapist introduced a more structured activity that provided the child with the opportunity to feel in control of her neighbor and to openly express her feelings to him.

During the last therapy session, the therapist and the child discussed the reasons for termination and their feelings about the abuse and her treatment. To view this moment as a positive event, the decision was made to mark the end of treatment with a “party”. The therapist also involved the child in puppet play to reinforce her ability to talk to her family if she were ever to be exposed to sexual abuse again.

Before starting the termination party, the therapist met with the girl’s parents primarily to discuss the conclusion of treatment, to discuss the girl’s gains and their thoughts and feelings about the abuse, to review helpful parenting techniques, and to discuss the potential recurrence of symptomatology related to the sexual abuse at various developmental milestones. The girl’s parents were also given information regarding normative child sexual behavior in order to help them react appropriately to any sexual play that the child may engage in. The therapist met briefly with the child to discuss her feelings about the termination. The entire family then joined in the party.

Results

To evaluate the treatment gains, girl’s mother was asked to complete the CBCL again (CBCL; Achenbach, 1991). At termination, all of the subscales of the CBCL were within the normal range. The significant items mentioned previously all had decreased from 1 to 0.

Follow-up

Follow-up was conducted 8 months after the termination of treatment. The girl’s mother did not report any further concerns regarding the girl’s emotional or behavioral functioning. A follow-up CBCL (CBCL; Achenbach, 1991) was administered, from which a nonclinical profile emerged with the exception of the Anxious / Depressed scale. In comparing with the initial assessment, the Social Problems and Thought Problems scales returned into normal range, as well as all items that were previously significant.

Discussion

Control is a central issue in treatment of children who have been sexually abused. For Cognitive-Behavioral Play Therapy to be effective, it must provide structured and goal-directed activities, as well as allow time allow the opportunity for unstructured play, through which the child may convey information that might not arise if sessions are entirely structured and therapist-directed. The directive component of Cognitive-Behavioral Play Therapy is advantageous, since these children tend to avoid all matters related to the abuse in an effort to avoid the anxiety and negative emotions.

Cognitive-Behavioral Play Therapy can be effective with a wide range of sexually abused children (Ruma, 1993). However, the specific treatment described in this case cannot be generalized to the children who have suffered more extensive abuse, in which case both the type and duration of treatment may vary.

Bibliografia
Beitchman, J. H., Zucker, K. J., Hood, J. E., da Costa, G. A., & Akman, D. (1991). A review of the short-term effects of child sexual abuse. Child Abuse and Neglect, 15, 537–556.
Browne, A., & Finkelhor, D. (1986). Initial and long-term effects: A review of the research. In D. Finkelhor, S. Araji, L. Baron, A. Browne, S. Doyle Peters, & G. Wyatt (Eds.), A sourcebook on child sexual abuse (pp. 143–179). Beverly Hills, CA: Sage.
Finkelhor, D. (1990). Early and long-term effects of child sexual abuse: An update. Professional Psychology: Research and Practice, 21, 325–330.
Green, A. H. (1993). Child sexual abuse: Immediate and long-term effects and inter- vention. Journal of the American Academy of Child and Adolescent Psychiatry, 32, 890–902.
Kendall-Tackett, K. A., Williams, L. M., & Finkelhor, D. (1993). Impact of sexual abuse on children: A review and synthesis of recent empirical studies. Psychological Bulletin, 113, 164–180.
Knell, S.M. (1993). Cognitive -Behavioral Play Therapy. New Jersey: Jason Aronson.
Knell, S.M. (1998). Il gioco in psicoterapia: nuove applicazioni cliniche, Edizione italiana a cura di Francesca Pergolizzi, McGraw-Hill Companies.
Knell, S.M. & Ruma, C.D. (2003). Play therapy with a sexually abused child.  In M. A. Reinecke, F.M.
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