Treatment Issues

Some basic goals of trauma therapy during this stage are to form a therapeutic relationship; provide both verbal and nonverbal opportunities for the expression of complex feelings; and help the child to experience feelings of empowerment through drama, art, play, movement, and other expressive means. For abused children, additional goals are exploring feelings about an abusive past using expressive modalities, working toward sublimation of aggressive or sexual impulses, and helping the child formulate basic rules of safety and sexual abuse prevention skills. Other therapy goals need to be individualized for each child in treatment.

At about age 7 or 8, the child’s ability to move between the past and the present and to make anticipatory images allows the client to begin to work on issues through the therapist’s presentation of hypothetical situations. No longer does the child need to rely on repetition of what has been taught but rather is now capable of actually creating a solution to a set problem.

Demetrius continued to draw bottomless pits, almost reveling in the story of the person falling forever. Realizing that Demetrius’s repetition was not helping him and that in fact he appeared to be stuck,

I tentatively took a more active role in his stories. In one particular variation on this theme, Demetrius drew a story about a man in an airplane (Figure 7.2). The plane exploded, he explained, and the man had no parachute, so he was falling. Normally, this would be the end of his picture and the end of the story. “Demetrius, what would happen if the story continued and didn’t end here? I wonder what might happen next?” I asked. Demetrius then drew a volcano and said the man was going to fall into the volcano, which was a bottomless pit. Feeling more hopeless, I wondered what else might happen. Demetrius decided the man could fall into a soft snowbank instead, where he might freeze to death. I wondered aloud again what other possibilities might exist. Finally, Demetrius drew a small Indian village at the base of the mountain. An Indian hunter found the man, arranged for a rescue party, and took the man to his new home (Figure 7.3).

What was important in this interaction was that I merely suggested to Demetrius the possibility of a new ending, which he could accept or reject. The fact that he was able to work with it indicates that he was ready to do so, but he needed my assistance in knowing how to get there. By staying in Demetrius’s metaphor, but encouraging him to devise a satisfactory ending to this story, I was helping him to find the curative path in his repetition.

For sexually abused children, sexual activity may persist throughout latency, although some children may be capable of formulating subli- matory activities. The child continues to need consequences for sexual behavior, and the consequences need to be age appropriate as the child gets older and understands more about why the behavior is unacceptable.

Nine-year-old Demetrius's picture of a man in an airplane

Figure 7.2. Nine-year-old Demetrius's picture of a man in an airplane

Nine-year-old Demetrius's picture of a rescue

Figure 7.3. Nine-year-old Demetrius's picture of a rescue

For example, whereas earlier the consequence was only to remove a child temporarily from a situation, a child of this age is making more conscious choices about behavior. Therefore, the parent needs to up the ante in terms of consequences. An appropriate consequence might be that the child cannot do sleepovers, a popular activity for children of this age. If the child is known to act out sexually in more innocuous situations, he or she certainly cannot be trusted to do any sleepovers. This rationale can be explained to the child, giving a strong message that this behavior is not acceptable. There can be no exceptions to the consequence until the behavior is known to have ceased.

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