ABSTRACT: This paper describes teaching sexually abused youth how to utilize social support to undermine the powerlessness, isolation, self-destructiveness and vulnerability to further victimization that is characteristic of abused adolescents in residential care. The child care role described is present-focused, proactive and complementary to the other clinical interventions commonly employed with these youth. The work described evolved over several years of practice and it is offered in the hope that it will prove useful to child care workers dealing with adolescents abused as children.
The improvement of child protection laws in the late 1960s increased the recognition of, and concern for, childhood victims of sexual abuse. Since then surveys have consistently indicated that the sexual abuse of children is common (Herman et al., 1986; Finkelhor, 1979) and that many of these youth endure persisting negative effects well into adulthood (Gelinas, 1983). Even with the proliferation of community-based programs designed to both prevent and ameliorate the negative effects of sexual abuse, sexually abused children continue to be placed in residential treatment centers.
While the number of youth in residential care who have been sexually abused cannot be stated unequivocably, research indicates that the more restrictive or intense the level of care studied, the more common sexual abuse is (Browne and Finkelhor, 1986; Rosenfeld, 1979). Indeed, I have worked in residential programs where the rate approached 70% and have seen published reports placing the incidence in residential systems as high as 64% (Krenk, 1984). Consequently, residential treatment centers for adolescents should expect a high number of sexual abuse victims in any given program.
Most treatment programs for sexually abused youth are community based and emphasize an intensive and comprehensive course of individual, family, and group therapy for victims, offenders, and collaterals. Assessments of these programs have been generally optimistic (Giaretto, 1976, 1982; Sturkie, 1983; Begart, 1986; Gagliano, 1987; Frederich, 1987) and residential treatment centers have, for the most part, simply borrowed these clinical intervention systems. Since these programs make use of out of home placement for protective purposes only, the foster care professional’s involvement is largely and unfortunately custodial. As a result, the role the cottage program and the child care worker can play in helping these youth has not been adequately elaborated. This paper will describe the role milieu programming and the youth care worker can play in supplementing and enhancing the other treatment sexually abused youth in care receive.
Post Traumatic Stress Disorder
Because many teens who have been sexually abused continue to experience a subjective sense of stress and continue to have many social and psychological problems in spite of progress in therapy (Kerner, 1985), the Post Traumatic Stress Disorder (PTSD) diagnosis is being applied with increasing frequency. Indeed, the most needy and difficult residents are often those who were abused, even when the reason for placement ostensibly had nothing to do with sexual abuse; the PTSD diagnosis captures the chronic vulnerability to crisis and dysfunction these youth present.
PTSD recognizes that overwhelming life experiences are continually re-experienced, with attendant symptomatic behavior of varying consequences, until the trauma has been integrated into the totality of the victim’s life experience (van der Kolk, 1987). While the label itself and the clinical approaches associated with the disorder are of limited utility to child care workers, the formulation does explain why abused residents are chronically vulnerable to disturbance and dysfunction.
For example, in their work on trauma Horowitz (1976) and Krystal (1984) found that as children develop new cognitive sets and new defensive operations a trauma experience will be worked through again and again irrespective of the quality of resolution at an earlier age. Consequently, residents who use therapy successfully, that is, those who develop new ways of thinking and managing feelings, may be especially at risk. Child care workers need to understand and anticipate this vulnerability in order to help the youth in their care cope as effectively as possible.
A traditional milieu therapy program is ideally organized to provide important care to PTSD youth. Child care workers have often been asked to understand the significance of a child's past while working in the present to prevent further problematic behavior from occurring. In this tradition, effective child care work focuses the child on recognizing the specific difficulties that arise from her coping strategies and then assists her in the development of specific actions which will more completely meet her needs. The effective child care worker focuses the youth’s attention on developing effective behavior rather than eliminating problems, increasing, rather than limiting, the child's behavioral repertoire. For example, helping a youth recognize her impulsivity and its consequences, then helping her plan a strategy of thinking before acting, is similar to helping a sexually abused youth recognize how a sense of shame prevents her from acting assertively. The PTSD diagnosis can focus the youth worker and the youth specifically on the cognitive and behavioral sequels of abuse.
What exactly are the difficulties to which abuse victims are vulnerable? And what can these youth do now to prevent these difficulties from occurring? Specifically, these youth are vulnerable to low self-esteem and are less competent at handling feelings, relationships and social role expectations. They are prone to becoming isolated and are susceptible to being victimized again and again in important relationships. In placement these are the adolescents who are victimized by their boyfriends, who run away when things are going well, and who seem to fail for inexplicable reasons.
In care, sexually abused youth are most vulnerable when the stress associated with developmental tasks such as dating, establishing close relationships with peers, and planning for the future overwhelms the youth’s coping style. When this happens, the abused adolescent’s inability to share feelings and concerns, ask for help, and use support prevents the development of new strategies and results in the isolation and depression that can lead to crisis and acting out. This pattern is characteristic of adult PTSD clients and is a pattern that often can defeat the most determined of residential programs.
The PTSD perspective, however, provides child care workers with a concrete frame of reference from which to work: a vulnerability to crisis is simply an understandable, even expected, consequence of being abused and particular supports are needed to develop effective coping strategies. Moreover, by explaining the youth’s acting out and providing a sense of direction, the PTSD diagnosis protects staff from discouragement and burnout.
Adolescents with whom I have worked accepted easily and understood the notion that they could be vulnerable to crisis because abuse had made them more cautious and less open to help from others. It is a view of their problems that does not arouse defensiveness; it is consistent with how they feel and how they define their difficulties and, importantly, it suggests a comprehensible solution: learn the skills necessary to overcome, “survive,” the abuse experience.
The term “survivor” is commonly employed to describe victims who have integrated the abuse into their life and moved on. The term is familiar and it projects a powerful image of healthy psychological functioning. For the cottage program to play a key role in helping sexually abused youth “survive” it must articulate an effective behavioral definition of survival and teach residents how to create and sustain the survivor role. One way to do this is to undermine the powerlessness and stigma that immobilizes and isolates the abused youth. This may be done by teaching her how to access the supportive potential of her environment.
Social skills training
A social skills focus is a powerful complement to other clinical services; providing the focus may be the most potent role a child care worker can play. A skill deficit suggests a solution: learn the necessary skills. In addition, there is a growing body of knowledge about how to teach social skills and the child care worker is ideally positioned to provide instruction at precisely the times it is most needed.
Generally, a social skills training program has three crucial dimensions: enhancing the child's knowledge of the skill, translating that knowledge into specific behaviors, and fostering the maintenance of the skill (Gardner et al., 1987). In other words, the youth needs information about the skill and support to perform and continue the effort. Fox and Krueger (1987) identify a more specific range of techniques: modelling, rehearsing, reinforcing, feedback and correction. I will discuss below how child care workers can use these techniques to teach sexually abused youth critical survival skills.
Sexually abused youth need two kinds of information: a common-sense understanding of PTSD and the potential difficulties they are vulnerable to, and an understanding of how specific skills can prevent future symptomatic behavior. A specific listing of the requisite skills includes:
the ability to accurately assess situations and people;
the ability to share information and feelings with others;
the ability to secure and use information and feedback;
the ability to influence situations.
One way to provide youth with information about PTSD and the potential effects of sexual abuse is to have the residents read published accounts of the problems encountered by some adults who were abused as children. Another way to provide information is to arrange discussions between residents and adults abused as children. Information about the skills these youth need is most usefully provided when informed child care workers, talking about current concerns and situations in which the teen is involved, stress that getting and using support is a crucial dimension of problem solving. When the importance of a skill, such as getting information from others, is consistently maintained as a focus in discussions the youth’s acquisition of the skill is enhanced.
It is important to note that youth do not have to share with or seek support from the child care worker alone. What is most important is that the child care worker explicitly models and values the notion of interpersonal connection and involve ment. In some instances support from peers is as, or more, crucial. To support the development of new and more effective patterns of coping, child care workers can ask questions such as, “Are you handling this alone?” or suggest a task such as, “Get some ideas on this from a couple of different folks you trust; it’s too important to work on alone.”
Support-seeking skills are critical because learning how to share feelings with others and how to seek support undermines the interpersonal contexts that support and maintain abuse. By focusing on these skills in their day-to-day transactions with the residents, child care workers become an important source of information as well as powerful models.
Knowledge to action
Providing information and models, while powerful, is insufficient. Learning also requires a context in which the skills can be rehearsed and reinforced. A structured, though naturalistic, approach I advocate is developing a mutual aid group composed of people from all the significant settings in which the resident participates. In my experience this requires, at the very least, a teacher, a child care worker, and a social worker, meeting once a week with each adolescent in the program.
Composing the group on the dimension of its being representative of the adolescent’s significant settings accomplishes several critical purposes. First, the group is a concrete expression of the program’s commitment to openness and mutual support. Second, the group provides a forum for modelling, rehearsing, and enactment of skills. Third, the group demonstrates the efficacy of solving, or preventing, personal problems by accessing a social environment’s supportive capability. Fourth, the group provides a corrective emotional experience that directly challenges the youth’s fear of betrayal. Lastly, the group provides a valuable context for individualizing each resident’s milieu by getting the adolescent and representatives of each part of the program together frequently enough to ensure that everyone involved with the youth is informed and coordinated.
The group’s process can focus on choices the adolescents have made or will soon be making; their opinions about self; their standing with others; and the anticipation of how situations might challenge their ability to share, ask for help, or accept support. Sometimes good cheer and support are intervention enough, but sometimes serious problem solving and planning are required. Social situations ranging from dating to being on the school bus can be discussed if these situations are the context of a personal challenge. An example of how the group can proceed is summarized below.
B was a 16 year old high school senior who was bright, able, and well liked by staff. Placed in the residential program after an unsuccessful course of outpatient individual and family therapy for drug use, running away, and truancy, she seemed to flourish in placement. A treatment focus on developing the capacity to trust others and absolving herself of responsibility for sexual encounters with her stepfather was established. With positive results in marital therapy, a developing closeness with her mother, and court approved visitation proceeding smoothly the prognosis was promising. Unexpectedly B ran away, was absent for six days, and had to be returned by the police. Her absence had been spent “partying” with various young men who sheltered her in exchange for sex. Upon return she was described as exhausted, ill, angry, hostile, and abusive to others.
Exploration of the events preceding her running away revealed that she was fearful that her boyfriend was going to break up with her because she had begun having intercourse with him. Her view was that she was worthless and undesirable because of having engaged in intercourse and she was convinced that everyone at school knew what she had done. She found herself unwilling to share her concerns with parents, peers, or staff and running away from this situation seemed sensible to her.
B’s running away was assessed as the result of the challenge of a new developmental task, sexual intimacy with an opposite sex peer, undertaken in the absence of support from her social network.
The network’s weekly meetings with B began to focus on the ongoing demands of having a boyfriend and how sharing her concerns about this relationship could prevent symptomatic behavior. For example, one problem the group explored was B’s being invited to her boyfriend's house when she knew his parents wouldn’t be home. On the one hand she wanted to go to please him. On the other hand she was made uncomfortable by his eagerness, his obvious sexualized energy, and the “sneaky” quality of the plan which was reminiscent of the encounters with her stepfather. B’s ambivalence about sex, as well as her feelings of discomfort even talking about it, made this a difficult situation. Working through the reluctance to discuss intimate issues like this with others was a valuable opportunity for developing the skills that B would need when involved with men post placement. The work of the group was facilitated by some general questions such as, “Do you have enough information to feel confident about how to handle this?”; “Is there anything that you can do ahead of time to be more ready?”; “Is there anything any of us can do to help you?”; “Is there any thing in particular that makes you more uncertain of this situation than others?”; “What is the best choice for you?”
These meetings offered B suggestions such as talking it over with her boyfriend ahead of time, bringing it up in the survivors group, finding out what her peers thought, and seeing if others could be invited to his house, too. Staff offered their own experiences, as adolescents and as parents, in situations such as this one and provided B the opportunity to find out what others thought and to get information and advice she could use. The meeting offered concrete suggestions and resources, and activated appropriate problem solving while validating the difficulty and importance of such a decision. In these ways the network was able to provide a social context in which B could be coached to enact the behaviors which would limit her vulnerability to isolation and symptomatic behavior.
Maintaining the gains
In addition to promoting and reinforcing the acquisition of support-seeking skills in the protected and supervised environment of the cottage group, careful attention must be paid to helping the residents apply their skills in different settings. The composition of the group and the discussion's content are helpful in achieving this; however, before discharge, it is important for the youth to construct a support network in the setting to which she will be discharged. By placing responsibility on the youth to assemble and detail her support system and by promoting her participation in it prior to discharge, the program can maximize the likelihood that the skills learned will be prized and employed.
Even though the problems of sexually abused youth have received considerable attention over the past ten years, residential treatment centers have been slow to identify ways in which the unique assets of institutional care can be used to assist these youth. More often residential treatment programs have simply added treatment programs developed in community settings to the available mix in placement. This paper has attempted to remedy this by describing how a social skills training orientation can be tailored to the needs of adolescent abuse victims and delivered within the context of traditional milieu programming. The approach described has evolved over several years of practice; it is consistent with emerging clinical perspectives on, and approaches to, sexually abused youth; and most importantly, it more effectively exploits the treatment potential of the residential programs in which these youth are placed.
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This feature: Oles, T.P. (1991). Complementing the therapist: Child care work with sexually abused youth. Journal of Child and Youth Care, 5, 1. pp. 43-50.