Treatment Issues

Some basic goals of therapy at this stage are to help the child learn to recognize and discriminate between feelings and offer opportunity for the expression of feelings in multiexpressive modalities, encourage the exploration of internalization of the self as a bad object, and provide a nurturing environment where the child can experiment with a wider range of adaptive behavior. At this stage, the ability to attach or form a therapeutic relationship with the therapist is crucial to any work being accomplished. For abused children, an additional goal is to teach the child basic rules of safety and abuse-prevention skills. Other therapeutic goals, particularly related to behavior, should be individualized for the particular child in treatment.

Treatment issues that are particularly relevant for abused children involve the child’s internalization of guilt, shame, and sadness. The self as a bad object will be a long-term issue that is introduced at this stage. Because at this stage the boundary between fantasy and reality is blurred, the child feels responsible for the abuse. However, the child also has the ability, at the psychological level, to differentiate the self from the nonself. Separating out feelings about the perpetrator and the self is a key treatment issue.

In terms of therapy, psychoeducation aimed at teaching the child new responses is appropriate at this stage. Through repeating or copying images, the child can learn how to respond to abusive situations. It is a good time to read books to children about sexual abuse so that they can learn new responses. For example, after being read a book about touching problems, a 7-year-old girl spontaneously drew Figure 6.4. She said, “This is a happy face, a sad face, a dollar to buy things with, and a book. The book is about a girl and somebody touched her privates and she ran away. She ran home. Her mom was home and she told her mom about it. Her mom said, ‘That man cannot do that anymore.’ ” The scenario she depicted was very similar to the story read. The child’s means of processing at this stage was through simple repetition of the story.

The primary issues in psychoeducation at this stage are ones of safety. Children should be able to identify kinds of good touch and kinds of bad

Figure 6.4. A 7-year-old's depiction of a story just read

touch. Children should be able to identify who they can go to and tell if they feel unsafe. Children should be able to repeat simple safety rules.

Because so many of the safety rules require the child to be able to discriminate between feelings (Liang, Bogat, & McGrath, 1993)—both one’s

Figure 6.5. A 5-year-old's depiction of "happy" (cropped image)

Figure 6.6. A 5-year-old's depiction of "sad" (cropped image)

Figure 6.7. A 5-year-old's depiction of "mad" (cropped image)

Figure 6.8. A 5-year-old's depiction of "scared" (cropped image)

own and someone else’s—much work needs to be done in the area of identification of simple feelings. Children at this stage should be able to identify “happy,” “mad,” “scared,” and “sad.” Children should be able to playact and make faces corresponding with these feelings and identify them through pictures. Drawing pictures can aid in the process of learning to identify feelings.

Five-year-old Elinore’s four pictures of feelings are typical of a child of this age and show how communication through art is possible (Figures 6.5 through 6.8). Despite Elinore’s limitations in art, distinct differences exist between her depictions of happy, sad, mad, and scared. Notice how descriptive she is in her use of encapsulation for the figures that represent sad and scared, which suggests isolation or possibly a need for protection. Despite her limited drawing skills, her artwork is reflective of her emotional world and egocentricity.

For children who have been severely abused, numbing of all feelings can be used as a defense, so it cannot be assumed that the child can discriminate between even simple feelings. Figure 6.9 is a drawing by a 4-year-old who is just beginning to develop a schema for feelings and faces. Often, children of this age mix up feelings like scared and sad; however, this child demonstrates a good understanding that coincides with her ability to playact effective faces that show these feelings.

One way to help children learn to recognize and discriminate between feelings is to offer opportunity for the expression of feelings in multiexpressive modalities. In addition to art, dollhouses, dolls, toy props, and other stimuli may provide the impetus the child needs.

Figure 6.9. A 4-year-old's depiction of "happy", "sad", and "scared"

DeMarcus was a 5-year-old boy whose abuse by an uncle included burning his feet in scalding water, head blows, and bums to his chest inflicted by a curling iron. DeMarcus’s play and art themes were consistently violent. He perceived his world as unsafe and chaotic. Repeated themes of tornadoes eating up people, monsters that bite, snakes that chase people, and physical battles between adults and children were typical for DeMarcus. DeMarcus played in the dollhouse. “This is a story about a man and a boy. The man gets up and gets dressed and asks the boy if he ate yet. He told the boy to sit on a chair and then the man laid on the couch to sleep. The boy got up and picked up the sink and threw it on the man. Then he went upstairs and threw the refrigerator on the man. Then the man and the boy went on the roof and the boy threw the man off the roof and he died.” Although themes of such violence are always a concern, the strength in DeMarcus was that he appeared to be containing this aggression within his play. His violent stories were balanced and tempered by delightful stories that included much detail and humor. There was no sign of him acting out aggressively at home or at school. He had a good support system and felt relatively safe now that his perpetrator was in jail. His mother and DeMarcus had a strong bond that obviously made him feel secure within himself.

Therapy could be relatively short, because he appeared to be gaining mastery over his feelings of powerlessness through play and was not acting out in his environment.

For the aggressive or sexually acting-out child, the parent or guardian must be involved in the therapy. At this age, as in the sensorimotor stage of development, children must be given consequences for behavior. The consequences are not punishments but relate directly to the acting out and are designed to help stop the behavior. The adult caretaker who observes the behavior must be very clear to the child that he or she cannot do these things and will be removed from the play situation every time the behavior occurs. If the child needs constant supervision, the caretakers must be willing to provide it.