Sublimation is one of the healing qualities inherent in the expressive arts and is something children at this stage employ as a natural course of development. This is exemplified in the case of 10-year-old Alicia (Klorer, 1995).

Alicia was a highly sexualized child, as can be seen in the “family portrait” that she spontaneously painted in a group art therapy session (Figure 7.4). Alicia’s sexual acting-out behavior was considered serious when her teachers began reporting frequent masturbation in school. Masturbation is a typical means of sexual expression for children, but certainly discretion should already have been learned by this age. Attempts to control this behavior through talking with Alicia were unsuccessful. Children in her class were beginning to ostracize her as a “nasty” girl, but this, too, had no apparent effect on the behavior, which seemed to increase with her classmates’ derogatory comments.

Alicia was introduced to the anatomically correct dolls in her therapy for sexual abuse. She almost always chose to play with the dolls during her session, seemingly fascinated by their genitals. In particular, she liked the baby inside the mother doll, which she pulled out and put back numerous times within a session. Alicia asked if she could make her own anatomical doll out of cloth. This was a long-term project that took many weeks to complete. Alicia wanted to replicate the mother doll exactly, including a vaginal opening, uterus, and unborn baby, which could be “birthed” repeatedly (Figure 7.5). The doll was not allowed to leave the office until she was fully clothed, so Alicia found some doll clothes that fit her. Once completed, this doll took on an important role in Alicia’s therapy. Though she was not allowed to take the doll to school,

Painting of her family by 10-year-old Alicia

Figure 7.4. Painting of her family by 10-year-old Alicia

she kept it close to her side while in her cottage and brought it to therapy sessions, like a transitional object. Her play with the doll became very specific and frequent. She began birthing the baby doll repeatedly. The motions actually took the form of masturbation, as the doll was pulled out and pushed back into the vaginal opening up to a hundred times within the course of an evening at home, much to the consternation of her houseparents. The houseparents were urged to let the play continue as long as it was within the house. This play ultimately led to a decrease in her masturbatory behavior, as she was able to gain mastery over these sexual impulses through the substitution of the doll. As with a true transitional object, over time the doll lost meaning for her. She left it in my office one day and never retrieved it. Shortly thereafter, she left the treatment center to live in a preadoptive home. Reportedly, the masturbation behavior did not occur in her new school. Alicia’s substitution of the doll for her own sexual acting out was an age-appropriate response dependent upon her achievement of ego activities that were subli- matory, adaptive, and defensive.

Anatomical doll created by 10-year-old Alicia

Figure 7.5. Anatomical doll created by 10-year-old Alicia

At this stage, avoidance of sexuality may be seen in the company the child prefers to keep. Generally, girls are more comfortable in the company of girls and boys are more comfortable in the company of boys. Same-sex group therapy, then, becomes an effective therapeutic modality; however, the therapist needs to be attuned to individual children’s coping styles and adjust therapeutic goals to fit the needs of each. Socially, the child no longer operates only in dyadic relationships but proceeds to more complex systems of relationship (Greenspan, 1979). Initially, the purpose of group therapy is simply to help the child feel less alone with trauma issues. Children are not necessarily ready to empathize with other victims but benefit from knowing that others have experienced what they have experienced. As children become more peer-oriented (at the gang age, from about 9 to 12), the therapist can work with them on identification with the group. Children can begin to talk to one another within the group, rather than approaching the group as if it were simultaneous individual therapies. Eventually, children will also be able to employ the development of new affects, such as empathy, in their repertoire of feelings. They will be more able to identify and empathize with one another and to note similarities and differences between each other’s experiences. Altruistic feelings, greater social awareness, intellectual gains that allow for an integration of primary and secondary process thinking, and the employment of judgment and logic to situations help children gain in stability and mastery of the environment. Thus they can use each other’s as well as their own experiences to process feelings and learn appropriate coping responses in potential sexually abusive situations. Drama therapy is a wonderful addition to group sessions at this stage, as it allows children to “try on” different roles and feelings.

At the stage of concrete operations, the child develops the ability to classify. This helps the child to master concepts in mathematics (Piaget & Inhelder, 1969; Silver, 1990); it also helps the child to classify feelings, by both generalizing and discriminating between feelings (Greenspan, 1979).

Feelings picture by Janice, age 7 (therapist wrote words for her)

Figure 7.6. Feelings picture by Janice, age 7 (therapist wrote words for her)

Figure 7.6 is an example of some of the complexities of feelings the concrete operational child is capable of articulating.

The artist, Janice, is the younger of two siblings who were referred for therapy because of their repeated sexual acting-out behavior in the home. Although the 12-year-old was seen as the initiator, Janice, a 7-year-old, was eagerly participating and was taking the new behavior to school. In therapy, Janice asked if she could draw what her 12-year-old sister does to her at night. She drew herself in her bed crying. When asked how she feels, she said she feels mad, but then it feels good and sometimes she likes it. I asked her to name all the feelings, and I wrote them on the picture for her. She said, “Horrible, stupid, worried, abused, scared, ugly.” This session represented considerable insight, and the fact that she could identify both liking the abuse and hating it suggested that she was ready to look at her own role in the sexual activity that was occurring.

The child is capable of more advanced understanding of feelings and gradations of feelings and can understand the concept of feeling several different things at the same time. However, denial is a key defense, so the therapist may need to recognize that talking with the child specifically about what happened is not easy at this stage. Janice clearly was ready to talk about her abuse and used art to help herself process her feelings. Had she not been able to talk so directly, consequences for the sexual acting-out behavior would have been initiated, and psychoeducation aimed at abuse prevention would have been the focus of therapy. Thus, unless it is particularly relevant for a certain child, the therapist should not be too concerned about pressing for the disclosure of details about the abuse as long as the psychoeducation aimed at preventive skills is completed and consequences are being administered consistently. The child will talk when it is safe to talk.

The child takes the first steps toward moral development at this stage, so the concept of right versus wrong can be introduced. The child can see how the behavior can be wrong and that it does not mean that the child is wrong or bad.

Several weeks later, Janice and I discussed how she has control and can make her own decision about sexually acting out with her sister. Janice drew two pictures, one expressing “wrong” thinking and one expressing “right” thinking in regard to making a decision about whether to sexually act out. Her “wrong” picture (Figure 7.7) shows

"Wrong" thinking, by Janice, age 7 (therapist wrote words for her)

Figure 7.7. "Wrong" thinking, by Janice, age 7 (therapist wrote words for her)

her thinking, “I want to. I don’t want to. She wants to. I can feel it. Gussie will get mad. I don’t want her to get depressed at me. Nah, go ahead and do it.” Her “right” picture (Figure 7.8) shows her thinking, “I don’t want to. I’ll get angry with myself and have to suffer the consequences if I do it. No! Leave me alone. I’m going to tell a grown-up.” The beginnings of moral development for this child were tenuous and notice that one of her reasons for not acting out is because “Gussie will get mad.” She has not yet internalized this value, but her picture shows a good beginning with this struggle.

In terms of psychoeducation for sexual abuse prevention, at this stage the child can logically understand the meaning behind safety precautions that previously were simply repeated. Children can help formulate safety precautions related specifically to their individual situations. In this context, children should be able to identify specific persons to whom they could go if in trouble, identify situations in their own lives that are not safe, identify kinds of touch (good, bad, confusing), and identify and take ownership of feelings.

During the previous stage, children were able to repeat stories presented and act them out. Now, the child’s ability to move between the past and the present and make anticipatory images allows the child to create solutions to

"Right" thinking, by Janice, age 7

Figure 7.8. "Right" thinking, by Janice, age 7

a hypothetical situation presented by the therapist. In addition, the child is capable of creating his or her own scenarios. Therefore, in psychoeducation groups, children can play act stories of abuse and find their own solutions. For example, anatomical dolls can be used to set up scenarios of potentially abusive situations. Children can then act out different possibilities of coping. The child’s ability to make anticipatory images or suggest movements, despite the fact that they have not been observed yet, can be seen in the following case vignette (Klorer, 1995).

Three girls between the ages of 7 and 9 were seen in weekly group therapy. Some psychoeducation aimed at sexual abuse prevention had been introduced. The sessions were both directive and nondirective, depending upon the goals for a particular week. During nondirective sessions, the girls frequently chose to play with the anatomical dolls because the dolls stimulated their issues of sexuality. The girls began incorporating the dolls into stories. Invariably, the stories revolved around a mean perpetrator sexually abusing a young girl. A policeman would then rescue her. This was a new story, not one that had previously been read to them. The girls would then act out the child’s role in prosecution and punishment of the perpetrator, empowering themselves in the process. The children demonstrated their abilities to create a solution to a set problem based upon their own experiences, but one also involving their wish for more power in the resolution.

Therapy at this stage of development focuses on the child’s feelings of powerlessness in the face of trauma. Expressive therapies are used as a means of helping children express those feelings and issues that are avoided and denied verbally. Expressive work gives them a safe avenue by which to approach the issues and often precedes verbal disclosure and processing. It is important that the therapist stay with the child’s level of denial and support the process of allowing the issues to unfold as the child becomes ready to experience them.

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