One of the most widely published statistics on child sexual abuse, from the Centers for Disease Control and Prevention in 2005, asserts that 1 in 4 girls and 1 in 6 boys are sexually abused before the age of 18. Furthermore, research by John Read and colleagues in 2004 estimated that 50 percent of adult women and 28 percent of adult men who seek counseling have a history of being abused sexually as children. These statistics point to the high probability that counselors, regardless of their practice setting, will encounter child victims and adult survivors of child sexual abuse.

Unfortunately, few counselors have received specific training with this population, and many practitioners report that they are not adequately prepared to provide counseling to trauma survivors. Counselors’ lack of readiness to address child sexual abuse has numerous consequences. These include failing to inquire about the client’s abuse history, failing to provide a therapeutic response to the client’s abuse disclosure, shifting focus due to an inability to hear the details of the client’s abuse and making inappropriate referrals. Additionally, counselors who lack training to work with victims of sexual abuse may struggle to understand the world of the victim or may experience their own countertransference. Lack of training may also increase counselors’ risk for burnout and vicarious traumatization.

The experiences of child victims of sexual abuse

Counselors may have a narrow understanding of the experiences of child victims of sexual abuse due to the limited research that has been conducted with these children. Most published studies focus on the retrospective memories of adults, predominately women. To address this gap, in 2011 I conducted the first known study exploring children’s written descriptions of life before, during and after sexual abuse through a qualitative analysis of trauma narratives.

The analysis revealed a meta-theme, which was titled “Fear and Safety.” All 21 children (18 girls and three boys) in the study reported fears, including during the sexual abuse, during their attempts to stop the perpetrator and during the disclosure. Fear and issues of safety were also present in children’s discussions of their life now (for example, in nightmares and flashbacks) and in their thoughts about the future. A follow-up study in 2014 explored 19 boys’ narratives and confirmed the meta-theme of fear and safety.

Child victims of sexual abuse often view the world as unsafe, and they are likely to enter counseling with unresolved fears. They need help from their counselor to learn how to cope with their fears and how to increase their internal and external resources. Additionally, these children need an opportunity to voice their unspeakable experiences. Because fear is a central part of the child victim’s experience, counselors need to be prepared to implement interventions that address past, present and future fears.

Interventions that target fears

Several treatment models, strategies and techniques are effective in addressing children’s fears related to child sexual abuse, including the following interventions.

Trauma-focused cognitive behavior therapy (TF-CBT) is a comprehensive, evidence-based treatment model developed by Judith Cohen, Anthony Mannarino and Esther Deblinger. It was designed to address traumas and crises experienced by children, including child sexual abuse. According to a meta-analysis conducted by Wendy Silverman and colleagues in 2008, TF-CBT was significantly more effective than placebo and other forms of trauma treatment designed for children and adolescents.

Unlike other models, TF-CBT specifically targets trauma-related fears through a variety of interventions. One of these interventions is the trauma narrative, in which child victims describe in their own words their experiences before, during and after sexual abuse. For those interested in learning more about TF-CBT, a manual titled “How to Implement Trauma-Focused Cognitive Behavioral Therapy,” created by the National Child Traumatic Stress Network, is available at nctsnet.org/nctsn_assets/pdfs/TF-CBT_Implementation_Manual.pdf. Additionally, counselors and counselors-in-training can enroll in a free 10-hour training in the model, available at tfcbt.musc.edu/.

The “safe place” technique is an intervention designed to help children cope with their fears. The strategy can be taught and practiced during counseling sessions so that child victims of sexual abuse can implement it outside of counseling when fears arise. Counselors start by providing information to children (and, if possible, their parents/caregivers) about the technique and how it can help combat fears. Counselors then help children create their own imaginary safe place by asking questions that encourage children to vividly describe their special place.

For example, the counselor may say, “Close your eyes and picture a special place where you feel completely safe.” The counselor then follows up by asking questions that capture additional details, such as “What do you see? What do you hear? What do you feel? What are you doing in your safe place?” The counselor records these details and uses them to create a script.

Similar to other guided imagery scripts, the safe place script often begins with asking children to close their eyes and take several slow breaths. Many children enjoy using the safe place script as a closing ritual to their individual sessions. This can be especially helpful when the sessions have focused on processing their traumatic experiences.

The safe place script can also serve as a springboard into an expressive arts intervention in which children have an opportunity to create their safe place in a drawing or painting or with clay. This extension of the technique may help children better picture and describe their special place.

The comfort kit (also referred to as the “feel better bag”) was developed by Liana Lowenstein in 1999. Its original purpose was to help children who engage in nonsuicidal self-injury to learn self-soothing strategies, but the intervention can be tailored to meet the needs of child victims of sexual abuse by providing them with a tactile strategy for coping with fear.

The intervention begins with psychoeducation for the child (and, if possible, the parents/caregivers) about the technique. Counselors then help children brainstorm and create a list of items that bring them comfort and make them feel better. Although the counselor guides the process, it is the children who choose what will go inside their box or bag.

Common items that children include are their safe place script, a blanket, music, a favorite stuffed animal, guided imagery (either written or recorded), a stress ball, a list of relaxation activities, bubbles (for deep breathing exercises), a favorite book, a picture of a caring person or special place, a journal and pen, art supplies and a list of self-affirmations. Children then select a container that can hold the items they have selected. The child can decorate the outside of the container, and directions on how to use the comfort kit can be adhered to the inside of the box.

Lifeline is an experiential exercise, described in the literature by Maggie Schauer and colleagues in 2003, that provides a creative way for children to tell their story. The idea of talking about their experiences may be especially daunting for children who have been sexually abused. This unique approach helps them begin the process of sharing their experiences in the safety of the therapeutic relationship.

The intervention begins with the counselor providing the child with a long rope that is spread out across the room. Part of the rope will be used, while some at the end will remain unused (this represents the future). Counselors explain that the rope is a timeline of the child’s life and experiences, both good and bad. Some children may benefit from having numbers written on paper and distributed along the line to represent their various ages. The child is then asked to select two types of objects to mark his or her experiences. One of the objects is used to represent positive experiences, whereas the other object represents negative experiences. For example, flowers could mark positive experiences and stones negative experiences.

As children place the objects along their lifelines, they name their experiences. To specifically illuminate children’s fears, the counselor can ask them to mark situations in which they felt fear. Present fears can also be explored. Once children are done marking significant life events and experiences, they can process the experience with the counselor. For older children, the unused part of the rope (the future) can be explored through questions such as: What positive events do you hope to see in your future? What fears do you have about the future?

To preserve the experience, a photograph can be taken of the lifeline. Children can also be given the opportunity to draw or paint their lifelines. This allows the counselor and child to refer back to the lifeline throughout counseling. This may be especially beneficial when past, present and future fears related to child sexual abuse are explored.

Bibliotherapy is an intervention that has a long history of use with children for a wide range of presenting concerns. It is especially relevant for children who have experienced sexual abuse. Children’s books about sexual abuse can introduce child victims to others who have endured similar experiences, which may lead to decreased feelings of isolation and normalize their trauma-related symptoms. Furthermore, books about abuse can provide comfort, teach important lessons (including that the abuse was not the child’s fault) and offer suggestions for coping. Additionally, some books assist child victims in recognizing their internal strength and identifying safe people who can provide them with support.

Because fear is a predominant issue for child victims of sexual abuse, stories that specifically address feeling afraid may be helpful. Once Upon a Time …Therapeutic Stories That Teach & Heal, written by Nancy Davis, provides counselors with several stories designed specifically for children who feel afraid. A Terrible Thing Happened, by Margaret Holmes, a story for children who have witnessed violence or trauma, is another resource for counselors who are addressing fear and its related symptoms with child victims of sexual abuse. The book is written in vague language so that children who have experienced a wide range of traumatic experiences, including sexual abuse, are able to relate with the main character. The Secret: Art & Healing From Sexual Abuse by Francie Lyshak-Stelzer is another book that would be appropriate to help older adolescents explore their memories and current feelings about their sexual abuse. The artwork painted by the author is powerful, and it succeeds in capturing the numerous feelings, including fear, related to abuse experiences.

Summary

Understanding the experiences of child victims of sexual abuse, specifically their fears and concerns about safety, is an important factor in providing effective treatment. The interventions described in this article provide counselors with strategies to help children express and process their fears in the safety of the therapeutic relationship.

TF-CBT provides an evidence-based approach that targets fears and reduces trauma-related symptoms. The trauma narrative, which is a component of TF-CBT, and the lifeline intervention both provide a way for children to share their stories and voice their trauma-related fears. The comfort kit and safe place script equip children with coping strategies that can be used both during counseling sessions and outside of session. Stories about sexual abuse — especially those that address fear, provide education, reduce isolation and give children further opportunity to explore their personal experiences — are also helpful.

Together, these interventions provide counselors with tools that can help facilitate the healing journey for child victims of sexual abuse. 

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Knowledge Share articles are developed from sessions presented at American Counseling Association conferences.

Jennifer M. .Foster is an assistant professor of counselor education and counseling psychology at Western Michigan University (WMU). Before joining WMU, Foster worked as a licensed mental health counselor and professional school counselor in Florida. She received her doctorate in counselor education from the University of Central Florida (UCF), where her dissertation, “An Analysis of Trauma Narratives: Perceptions of Children on the Experience of Sexual Abuse,” earned the UCF College of Education Outstanding Dissertation Award. Contact her at jennifer.foster@wmich.edu.

Letters to the editor:  ct@counseling.org

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