A number of factors contribute to a successful therapeutic relationship with a child. The following concepts are especially important in developing the kind of relationship that supports a child’s exploration of the issues related to abuse and neglect.
Trust is a difficult issue for many abused and neglected children. A child who has been physically or sexually abused by a known or trusted person may be cautious in developing relationships. An abused child needs to form a trusting relationship with the therapist; that relationship must be secure enough to allow the child to begin to explore the actual abuse. The establishment of such a relationship requires great patience from the therapist, who may feel pressure from other parties involved with the child (e.g., CPS caseworkers and parents) to “make the child deal with the … abuse” before the child is ready to do so.144 A child will test the therapeutic relationship, calling upon the therapist to repeatedly demonstrate that he/she is willing to respond and attend to the child’s needs and behaviors.
Two very important goals in helping children recover from abuse and neglect relate to their future safety:
- Help the child internalize the right to safety and protection.
- Find ways to help the child cope with similar events in the future.
Attending to the child’s physical safety and emotional safety during therapy helps the child begin to address these issues and fosters the development of the therapeutic relationship.
Physical safety is often missing from the abused or neglected child’s experience. Parents or caretakers may not have paid attention to the child’s environment or behavior that was dangerous to the child’s safety and well-being. Thus, physical safety in the therapy room and during the session is often necessary and symbolic for the child.
Abused and neglected children often come to believe that they are unworthy of attention or that their safety and protection is not important. Some children develop a facade of invulnerability and take risks that can be dangerous or life threatening. Abused and neglected children may not care about the outcome of their behavior or may try to hurt themselves. Some children may not have learned to recognize that some actions and behaviors are dangerous and life threatening.
Assessing the child’s self-destructive behaviors and need for protection is an ongoing process. A young child, or a child with limited experiences or capacity to process information, may seek protection from the therapist as a primary means for establishing trust and a sense of security. Physically abused children may use provocative behavior to test the therapist to see if the relationship will include physical pain or punishment. Abandoned or neglected children may be surprised to find that the therapist is capable and willing to pay attention to their needs and behaviors. Sexually abused children may behave in a seductive manner or make inappropriate statements or comments to test the therapist’s boundaries and reactions to see if he/she will respond to the child in a sexual manner.
The therapist needs to assure the child’s physical safety in the following environments:
- Home and Social Environment. A child must be safe in his/her home and social environment in order to benefit from therapy. The therapist needs to ensure the safety of the child in the home at the initial intake and periodically throughout the therapeutic relationship about the safety of the child.
- § Therapeutic Environment. The clinician can ensure physical safety in the therapy session by maintaining an accident-free therapy room and by watching the child carefully as he/she uses the therapeutic toys and furniture. The clinician should help the child in and out of chairs; reach for toys and items on top shelves; and manage climbing, aggressive, and destructive behavior. The clinician must intervene in aggressive acting out between peers and help the child resolve conflicts in violence-free ways. Interventions that demonstrate that the therapist is there to protect the child from injury and attend to his/her physical and emotional needs help the child begin to internalize his/her right to safety and protection. The therapist becomes a role model for adult awareness and introduces behavior that attends to the child’s safety and well-being.
The therapist can use many methods to help the child understand and internalize the concepts of safety and protection. For example, “What if” games are useful for determining the child’s self-protective capacity and emotionally charged concerns regarding safety. In addition, Kreiger notes the following:145
- Communicate in word and action that the child is worthy of protection.
- Discuss past traumas and possible ways to avoid those dangers in the future.
- Enter into the child’s fantasy play and, within that context, introduce a protector.
A child separated from his/her family, or whose family has been disrupted by the discovery of abuse or neglect, needs to focus his/her energy on determining what will happen next and on maintaining emotional equilibrium. Some children who have experienced a loss may feel frighteningly sad, alone, and needy. Other children may feel strongly hostile toward themselves and others. Other children may have feelings of despair, worthlessness, and defectiveness.
Schmale and Engle add a fourth state that is much less intense in emotional tone and more energy-conserving.146 This state is characterized by withdrawal and vague sensations of numbness, emptiness, and hypochondriacal concerns. These various stances may indicate that the child’s energy for responding and interacting is depleted. The child needs to feel that his/her world is safe and somewhat predictable before he/she will have the physical or emotional energy to attend to the tasks of therapy. In such cases, the therapist or other professional can use the following to help children feel emotionally safe:
- Help the child become familiar with his/her new surroundings and circumstances.
- Remind the child of his/her strengths and accomplishments.
- § Teach and practice problem-solving skills, including:
– asking questions,
– seeking help from adults and peers,
– identifying choices and options within the new situation, and
– planning for contingencies.
- Acknowledge the frustration and challenges of a difficult situation.
It is important to identify and support the methods or strategies that the child uses to care for him/her self during and after the abuse. A child can begin to take pride in those attempts and recognize that he/she did the best he/she was capable of doing in a difficult situation. This supports the child’s attempts at managing an unmanageable situation and allows the child to hear that his/her attempts were important and worthy of recognition. When a therapist identifies and focuses on a child’s weaknesses or inadequacies, the therapist loses a means of connecting with the child based on strength, respect, and esteem. The therapist also risks forcing the child to deny or defend his/her thoughts, feelings, and behaviors. As a result, the child may become entrenched in counterproductive behaviors and may resist intervention.
Pacing the exploration of the abuse over a period of time and placing the abusive experiences in the context of the child’s overall life experience is more therapeutic than listing all the details and memories in one or two sessions. Most children will not have access to all the details or memories on demand and it is overwhelming for a child to confront the entire abuse experience at one time. Most children will resist.
A therapist monitors and addresses emotional safety by paying attention to the clues the child gives about his/her ability to manage his/her feelings and behavior during therapy. A child will not benefit from being pushed to his/her emotional or cognitive limits. When a child is pushed beyond his/her cognitive/emotional limits, he/she will have little or no energy left to soothe or comfort him/herself. The child may demonstrate this depletion of ego strengths or defenses by regressing, acting out at home, or refusing to participate in therapy. The following clues may indicate that the child is having difficulties with the subject:
- behavior changes, including distracting or avoidant behavior;
- attempts to change the topic of conversation;
- somatic complaints;
- complaints of boredom; or
- change in affect.
The therapeutic experience can be organized so that it does not overwhelm or exhaust the child. Some ways in which the therapeutic session can be structured are as follows:
- Examine one aspect of the abuse at a time.
- Create cycles of work and rest or play.
- Break the discussion into small increments that provide a sense of accomplishment at completing a task.
- Incorporate esteem-building experiences into the therapy session.
- Differentiate between past and current experiences.
- Allow the child time to reflect and think about new information.
- Allow the child to choose and discuss emotionally manageable subjects.
Identifying and attending to life experiences that were not abusive or neglectful is also an important part of therapy. This helps the child place the harmful experience in context and shows that maltreatment is only one of many factors or experiences that has impacted his/her life. The child then can identify skills and arenas that he/she is competent enough to manage or master.
Focusing on both positive and negative experiences can enhance the child’s sense of self. Attending to life experiences that do not include being abused helps the child expand his/her sense of self and identity. This allows the child to integrate the experience into an overall sense of self that is not based solely on victimization. It also initiates the grief process that many children need to experience in order to let go of old images, expectations, behaviors, and feelings.
Many behaviors that are initially perceived as resistance are really behaviors that are geared to monitor and manage anxiety generated by recall of the abuse experience. Fidgeting, fooling around, interrupting, asking inappropriate questions, and straying from the topic or task all need to be considered as possible coping behaviors that help a child disengage from his/her painful feelings and thoughts generated by the abuse.
The ego defenses or defensive maneuvers that a child uses to protect him/herself from overwhelming stimuli or memories related to the abuse experience need to be acknowledged and used so the child feels validated, capable, and able to survive in the best way he/she knows how. A child seldom lets go of a defense mechanism, a defensive shield, or protective maneuver simply because he/she is told to do so. Tailoring interventions that facilitate the child’s ability to process the experience and manage the anxiety and stress that are generated are important. A child will change his/her behavior when he/she feels capable of managing his/her world without that behavior. Most children will often do this at their own pace.
A child who is not willing to participate in therapy will not benefit from the therapeutic experience. However, there are many ways to help a child feel more comfortable about participating in therapy. These include the following:
- empathizing with the child’s frustration or fears about therapy;
- clarifying therapy and what will happen, including providing information that therapy does not mean the child is “crazy”;
- setting goals that are useful to the child; and
- contracting for a certain number of sessions with the option to continue counseling if necessary.
It is important to note, however, that not all resistant behavior means the child is unwilling to participate in therapy. Furthermore, the child may not understand what is expected of him/her within the therapeutic relationship. The child will benefit from clear descriptions of the purpose and benefits of therapy as well as clarification of how to think about and respond to questions, including the options of “not knowing” or “not wanting to say (yet).” It is also helpful for the clinician to explain and delineate appropriate behaviors in therapy, including appropriate therapistchild behavior. The clinician should also explore any fears or concerns that the child might have about therapy.