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Helping Sexually
Abused Children

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Acknowledgements

This manual was written by Dr. Jonathan Brakarsh and the

staff of the Family Support Trust. Many thanks go to
Sandra Morreira for her editing skills.

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TABLE OF CONTENTS
Page
1. BACKGROUND INFORMATION

1.1 Definitions of Sexual Abuse 3

1.2 What is The Extent of Child Abuse 5
1.3 What are the Factors Associated with Child Abuse 6
1.4 Indicators of Sexual Abuse 7
1.5 The Short and Long Term Effects of Sexual Abuse 10
1.6 Mediators in the Effects of Child Sexual Abuse 13
1.7 The Family’s Response to Sexual Abuse 14
1.8 The Context in Which the Child Lives 17
1.9 A Multi-Sectoral Approach to Child Abuse 18

2. COUNSELLING SKILLS AND TREATMENT STRATEGIES

2.1 How Children Communicate 20

2.2 How Children Communicate about Sexual Abuse 23
2.3 Structuring the Counselling Environment 23
2.4 Interviewing Skills 25
2.5 Obstacles in Interviewing children 26
2.6 Qualities of the Counsellor 27
2.7 Counselling Skills 28
2.8 A Model of Counselling 28
2.9 Play Therapy 30
2.10 Use of the Playroom 32
2.11 Use of Questions 32
2.12 Assessment versus Counselling 33
2.13 Working with the Family Support 36
2.14 Working with Groups 36
2.15 Preventing Revictimisation of the Child 38

3. ISSUES FOR THE THERAPIST

3.1 Burnout 38
3.2 Listening to Stories of Abuse 39
3.3 The Effects of Your Attitudes and Values 40

Appendices

Appendix A - The Intake Form 42

Appendix B - Guide to Using the Intake Form 47
Appendix C - Counselling Skills Checklist 52

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BACKGROUND INFORMATION
1.1 DEFINITIONS OF SEXUAL ABUSE
The sexual abuse of children crosses cultural and economic divides. Children’s
advocacy groups estimate that approximately 1 in 3 girls and 2 in 7 boys of the world’s
children are victims of sexual abuse. (Hesperian Foundation News Spring/Summer
1999). Child sexual abuse is when a child under the age of sixteen is used for sexual
gratification by another person (TARSC, The Sexual Abuse of Children, 1996).

Children are used for sexual gratification in various ways:

i. fondling of child’s sexual parts, i.e. genitals, breasts, buttocks;

ii. actual or attempted penetrative sex with a child, whether vaginal
(rape) or anal (sodomy);
iii. displaying or exposing a person’s genitals to a child (exhibitionism);
iv. displaying or exposing a child’s sexual parts;
v. oral sex with a child (i.e. mouth to sexual parts);
vi. having the child pose for pornography or watch sexual activities (voyeurism)

Legal Definitions of Sexual Abuse

Sexual abuse is not limited only to acts of penetration (rape). The legal profession
recognises that there are various types of sexual abuse ranging from indecent assault to
rape. These definitions are:

Rape is the intentional and unlawful sexual intercourse by a male over 14 years of age,
with a woman without her consent. Vaginal penetration even in the slightest degree is
sufficient and ejaculation by the male is not necessary. Boys under the age of 14 years
are regarded in the law as too young to commit rape. Hence if they are involved in
forced sex they are sent for rehabilitation but not tried.

Statutory Rape is unlawful sexual intercourse with any girl under the age of 16 years
with her consent. Girls under age of 12 years are legally incapable of consenting to
sexual intercourse. Consensual sexual intercourse with a child between the ages of 12
and 16 is statutory rape because a child is not regarded as old enough to make an
informed decision.

Incest is when a person intentionally has sexual intercourse with another person who is
a blood relative or related by marriage or adoption, and thus unable to contract a valid
marriage.

Sodomy is intentional anal intercourse with a male. The legal offence is seen as greater
if the victim did not consent. A child under the age of 16 is seen by the law as too young
to consent. Anal intercourse with a female is considered Indecent Assault.

Indecent Assault is intentional assault involving the sexual organs. This would include
such actions as oral sex, fondling, and attempted rape.

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Abduction is the act of intentionally taking a minor against the will of the parents,
guardians, or custodians of the minor with the intention of the person or another party
marrying or having sexual intercourse with the minor. A minor is any person under the
age of 18. The consent of the minor is irrelevant as the crime is in depriving the parents,
guardians, or custodians of their right to exercise parental control over the minor.

The question of ‘consent’

Children and adolescents are physically dependent on adults. Because of this
dependence on adults, they cannot be considered ‘free agents’. This is particularly
important when we are looking at the whole question of ‘consent’ to sexual activity with
an adult because they will always be in a less powerful position. True consent can only
occur between equals. Children are often forced, bribed or tricked into sexual activity
with adults and into keeping silent about the abuse. This does not mean that they have
consented to the abuse. The law recogonises this by saying that children under the age
of 16 are not consenting adults.

Medical Definitions of Sexual Abuse

(Iliff, 1998, The Management of Child Sexual Abuse.)
• Fresh genital or anal injuries in the absence of adequate medical explanation.
• The presence of sperm in or on the female body.
• Penetrative sexual abuse: vaginal, oral, or anal entry by means of penis, finger, or
object.
• Non-penetrative sexual abuse: exhibitionism, fondling, exposure to pornography,
or solicitation to engage in sexual behaviour.

Medical Indicators include:

• Urinary tract infections
• Genital pain or itchiness
• Abdominal pain
• Vaginal discharge, genital sores or warts
• Constipation or anal discomfort
• Bleeding from genital or anal area
• Pregnancy
• Presence of a foreign body in the vagina
• Discomfort when walking or sitting

It is important to note that the absence of physical findings neither confirms nor denies a
diagnosis of sexual abuse because the healing of the hymen and genital structures is
rapid.

Community Definitions of Sexual Abuse

In the rural communities and to a large degree the urban communities, rape is
considered the major form of sexual abuse. Families will rarely report any other form of
sexual abuse to the police or seek compensation from the abuser for acts of fondling the
child’s private parts, exhibitionism, oral sex and other forms of sexual abuse. For the
community the indicator of rape is that the child’s hymen is ruptured. If the hymen is
intact, the family will not take action.

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Cultural Definitions of Sexual Abuse

The community is responsible for the safety and protection of the child, not just the
biological parents. Within this context there are a number of cultural practices.
which involve children. Individuals have misused some of these customs as an excuse
to commit unacceptable acts against children. The Zimbabwe Traditional Healers
Association (ZINATHA) does not accept that any practice should be used in a way in a
way that allows a child to be involved in sex.

Descriptions of some of the cultural practices used in Zimbabwe to sexually abuse

children are:
Ngozi is a custom where a girl child is given as payment to the offended family to ward
off the avenging spirits of the family which they have offended.
Chiramu is when the husband of the older sister or the husband’s brother fondles one
of the younger sisters to begin to socialise her. The custom has been used as an
excuse to touch the private parts of girls or to encourage them to engage in sexual acts.
Kuzvarira is a custom where young girls are pledged in marriage.
Chinamwari is when a male elder teaches a newly married woman various sexual
techniques in order to please her husband.

Psychological Definitions of Sexual Abuse

The intention of sexual abuse is to arouse and/or control the child sexually. Sexual
abuse is psychologically confusing to the child. It is important to understand, therefore,
what distinguishes abusive from non-abusive acts. The Ackerman Institute (1991)
includes the following factors: -

- A power differential that implies that one party exerts some control over the other
and that the encounter is not mutually conceived and/or undertaken.

- A knowledge differential that stems from the fact that the offender is chronologically
older, and more intelligent than the victim; and

- A gratification differential that recognises that the purpose of the encounter is

the satisfaction of the offender and that any gratification of the victim is in the
interests of, or incidental to, the offender’s pleasure.

1.2 WHAT IS THE EXTENT OF CHILD ABUSE?

(from A Report on Child Sexual Abuse, TARSC, 1996)
Information is largely anecdotal. All studies indicate under-reporting due to:
- children not being able to verbalise that abuse has taken place
- threats by offenders, especially those familiar to children
- difficulties faced by children in reporting parents
- cultural factors of family privacy
- respect for adults by children
- barriers in the police and legal systems to accepting child information
- affected children (e.g.: street children) fear investigations
- children are not able to give adequate evidence in court
- stigma and social problems arising after reporting make people hide the problem
- lack of time and awareness in professionals in contact with children
- children learn to accommodate to the abuse as a way of surviving the experience

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Many cases thus appear due to their effects, e.g.: STD's and HIV in young girls after
sexual abuse, traumatic injury in physical abuse. Health workers identity the problems
when the injury is inconsistent with the history. The public health services are more likely
to report the abuse than private practitioners so that lower income groups using public
services may have higher reported cases.

Neighbours have reported cases, but often only after prolonged periods of abuse and
when the abuse seems to reach life-threatening levels.

1.3 WHAT ARE THE FACTORS ASSOCIATED WITH CHILD ABUSE?

Factors in society
Child abuse appears where there are vulnerable children (step children, disabled,
orphan, uniformed, poor, street children, children left for period by mothers) and family
or social problems (new marriages, poverty, displacement). The abuse appears to be
either a distorted or excessive use of an otherwise normal practice, often backed by
culture (early traditional marriage, excessive discipline, touching rights) or a violent act
emanating from severe mental/social stress, poverty etc. (e.g.: beatings, suicide
burnings, infanticide).

Poverty, certain aspects of traditional culture (and its distortion), unregulated and poor
social institutions, denial of abuse within the family, inadequate sensitivity of detection
and reporting of abuse and inadequate response to reporting of abuse create enabling
conditions for the continuation of child abuse.

Male to female sexual abuse, the more common form, is linked to male attitudes
towards and perceptions of their sexuality. Cultural sexual norms, indicating the females
are ready for marriage once menses have started, that males must satisfy sexual urges,
that women are expected to “struggle” in sex as a sign of their chasteness; sex for luck
or to cleanse from STD’s in traditional practices.

Cultural social norms may also contribute to abuse - such as child respect for adults;
culture of non interference in family disputes by other members of the community; male
dominance and status in employment, earnings, decision making and introduction of
new ideas and practices; greed for lobola from female children leading to child brides.

Where there is a lack of open communication and information to children, especially

about sexual parts of the body, risky adult behaviours and how to respond, it makes it
difficult for child to respond to abuse or to verbalise the experience.

Social crises, such as unemployment, retrenchment, migration, wars interact with and
increase the stress of family pressures. Overcrowded housing, leads to loss of privacy
and increases the risk of sexual abuse.

Factors in the Family

The emotional status of the parents: arises in parents who themselves have been
abused or severely criticised and unable to please their own parents or expected to
please parents more than their own needs. These adults develop low self esteem,
internalised high expectations together with inability to please, they appear as pseudo
independent, but have great repression of feelings, are isolated and distrustful. Their

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partners may be passive and often have similar histories. The child is thus blamed for
not being perfect as the child is expected to be the ”parent”. The abuse becomes an
expression of rage covering fear, with fear often the cause of the abuse.

Death of the adult parents, leading to step parenting and unstable home situations,
orphans (e.g. from AIDS), poverty and children (particularly female children) talking over
adult roles that leads to perception of them as also having adult sexual and social roles
and deprives them of the right to childhood.

Intolerable family situations may lead to children leaving home for the streets, such as
remarriage of the parent, divorce, economic hardship etc.

A passive, sick or absent mother leads to poor protection of children, and facilitates a
situation where other adults can take advantage of them.

Alcohol and drug abuse in the family, leading to poor control of adult behaviour.

Factors in the Child

Perceived difficulties in the child. Usually only one child in the family is perceived as
imperfect and identified as difficult to please given his/her inability to meet the parents
need for support. This may be a child who was a difficult delivery, premature or born at a
difficult time. In Zimbabwe many cases associated with the stepchild - i.e. the child of
another mother or father.

Children’s vulnerability and desire to please, curiosity and trust in children that exposes
them to risk; children are then made to feel responsible and so accommodate and allow
the situation to persist.

Disability in the child.

1.4 INDICATORS OF SEXUAL ABUSE

By observation alone, you can gain important clues to help you determine if a child has
been sexually abused. Even if a child refuses to talk, there are behavioural and physical
indicators, which suggest that a child has been sexually abused.

The strongest indicator, according to American research studies, is sexualised

behaviour (a child masturbating more, trying to touch the private parts of others, playing
at having sex or forcing another child to have sex). Many of these indicators also occur
when a child is experiencing significant psychological stress in their life. Consequently,
the professional must delve further to discover the source of the stress in the child’s life.

With any of the behavioural or physical indicators you should enquire further about the
child's life at home, at school, and with friends to determine if there are any events or
changes in the child’s life (family deaths, bullying, divorce) that require attention.

Behavioural Indicators
In young children - under five years of age:

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* Acting out sexual scenes with toys or dolls

* Excessive crying
* An increase in temper tantrums
* Increased clinginess
* Fears of a particular person or object

All Ages:

* Increased sexual content of vocabulary/obscene language

* Dislike of physical contact
* Defiant behaviour ("no-one can do anything to me")
* Nightmares
* Difficulty falling asleep/early morning waking
* Aggression towards others/bullying
* Self-destructive behaviours (cutting self, getting into accidents)
* Increased drug use (alcohol or mbanje)
* New fears
* Withdrawal from social contact
* Change in eating habits
* Decrease in energy
* Lack of concentration
* Change in school performance (drop in grades)
* Truancy/running away from home or school
* Bedwetting or soiling
* Sudden possession of money, new clothes or other gifts
* Compulsive masturbation
* Age-inappropriate knowledge of sexual behaviour
* Excessive curiosity about sexual issues and/or genitalia

Physical Indicators
* Unexplained pain, swelling, bleeding or irritation of the mouth, genital or anal area
* Sexually transmitted infections
* Change in gait (difficulty in walking)
* Increase in headaches/stomach aches, etc.
* Changes in appearance

Emotional Indicators
* Mood changes
* Worrying thoughts
* Increased anxiety

Normal sexual play compared to the behaviour of sexually abused children

Pathological sexual behaviours due to the child’s exposure to sexual abuse are
distinguishable from developmentally appropriate sexual play. To properly assess if a
child’s sexual behaviour is normal, it is important to know the development of normal
sexual behaviour in children. A table follows which provides a framework of appropriate
sexual behaviour in children (Sgroi, et al, 1988).

Children’s Sexuality

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Age Range Patterns of Activity Sexual Behaviours

Pre-School Intense curiosity Masturbation; looking at

each
(0-5 years) other’s bodies.

Primary School Game playing with peers Masturbation; looking at

each
(6-10 years) and younger children. other’s bodies; fondling of
and peers and other children in a
Pre-Adolescence game-like setting; sexual
(10-12 years) exposure of self to
others.

Adolescence Creating one’s identity Masturbation; voyeurism;

(13-CAPut!’ years) separate from one’s parents; simulated sexual intercourse;
practicing intimacy with peers. penetrative sex.

When children display premature sexual activity, there are two possible causes:

EXPERIENCE
or
EXPOSURE

The child may have experienced sexual contact with another child or adult and is
mimicking this behaviour. Or the child may have had exposure to explicit sexual
behaviour by being in close proximity to the sexual act, or by being exposed to
pornography.

There are two dimensions of disturbed sexual behaviour in children (Berliner et al,
1986). 1) Coercion. At its most extreme, coercive sexual behaviour results in the use of
physical force and injury. At its least extreme, an example would be one child forcing
another child to engage in sexual behaviour by using threats such as refusing to be the
child’s friend.

2) Developmentally precocious behaviour. This includes attempted intercourse by the

child as well as other inappropriate sexual behaviours:

- Touching or asking to touch another’s genitals

- Sexually stylised behaviours which imitate adult sexual relationships
- Persistent masturbation.

Sexual play between children:

* consensual
* developmentally appropriate behaviours

Sexually abusive behaviour between children:

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*coercive
*developmentally precocious behaviours

Sexual play between children is consensual – the children want to be involved and
perceive it as a safe situation. Secondly, sex play involves behaviours that are
developmentally expected (see preceding chart). In contrast, sexually abusive
behaviour between children is coercive – one person is forcing another through
psychological or physical intimidation to participate in an act without their consent.
Sexually abusive behaviour between children is also developmentally precocious –
the child is engaging in sexual acts that are not typical of their age group (see preceding
chart).

1.5 THE SHORT AND LONG-TERM EFFECTS OF SEXUAL ABUSE

Sexual abuse has both short and long-term effects upon the child.

Short-term Effects
* Feelings of powerlessness
* Anger
* Fear
* Increased anxiety
* Phobias (specific fears of objects or people)
* Nightmares
* Difficulty concentrating
* Flashbacks of the event
* Frequent vigilance of one's environment for fear of confronting the perpetrator

Long-term Effects
* Depression can be found more often in survivors of childhood sexual abuse than any
other symptom
* Chronic or severe anxiety is also associated with a history of sexual abuse
* Difficulties with trust and intimacy in relationships are also commonly seen
* Adult survivors of sexual abuse have a high incidence of being revictimised as adults
by battery, sexual assault or both.

Child hood sexual abuse can alter the child's view of the world as they grow up. Trauma
makes the child aware that dangerous events happen in the world. The sense of safety
that non-abused individuals have is shattered for abused children. The loss of hope and
security leaves the survivor living in a world that feels malevolent at worst, random at
best and over which she has no control in either case. The survivor’s assumptions about
the meaningfulness and benevolence of the world as well as the survivor’s degree of
personal effectiveness may be changed as a result of the sexual abuse. (Salter, 1995)

The Trauma of Sexual Abuse

Finkelhor (1986) an American psychologist, has looked at the traumatic effects of sexual
abuse upon children. A major effect of child sexual abuse is what Finkelhor calls
traumatic sexualisation " the process in which a child's sexuality (including both feelings
and sexual attitudes) is shaped in a developmentally inappropriate and interpersonally
dysfunctional fashion. The dynamics of the relationship between the offender and the

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child are outlined below as well as the psychological impact and behavioral
manifestations of traumatic sexualisation.

Dynamics
* Child rewarded for sexual behaviour inappropriate to developmental level
* Offender exchanges attention and affection for sex
* Sexual parts of the child fetishised
* Offender transmits misconceptions about sexual behaviour and morality to the child
* Conditioning of sexual activity with negative memories and emotions

Psychological Impact
* Increased awareness of sexual issues
* Confusion about sexual identity
* Confusion about sexual norms
* Confusion of sex with love and getting care
* Negative associations to sexual activities
* Aversion to sex or intimacy

Behavioural Manifestations
* Sexual preoccupations and compulsive sexual behaviours
* Precocious sexual activity
* Aggressive sexual behaviours
* Promiscuity
* Prostitution
* Sexual dysfunctions

Finkelhor also notes three other traumatic dynamics of sexual abuse. Namely,
stigmatisation, powerlessness and betrayal. These dynamics apply to both adults and
children, especially those who have been raped, and are referred to as the " rape
trauma syndrome ".

Stigmatisation
The individual feels that what is happening to them must be wrong, but they fear that if
they tell anyone they will be punished, rejected or disbelieved. Prior attempts have
proven this assumption true. Consequently, this stigmatisation further isolates the child
and increases his or her vulnerability to further abuse.

Powerlessness
Through the act of rape the individual has been forced to do something against their will.
Their sense and their body has been violated. The abuser has used their greater
physical or psychological strength to overcome the individual. In cases of ongoing
sexual abuse, the individual may feel that their actions are wrong but they do not have
the power to stop. The abuser has greater physical or psychological strength than they
do. This sense of powerlessness increases their feelings of self-blame.

Betrayal
There are two aspects. The first betrayal is the betrayal by the adult world. Most children
and adults feel that the world is a safe place; they don't have to be constantly watching
out for danger. This belief is shattered when a person is raped or sexually abused.

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The second aspect of betrayal is relevant for situations of prolonged child sexual abuse.
This is a betrayal of the " special " relationship between the abuser and the child. If the
child tells, he or she is betraying "their secret ". Since the child already feels powerless
and consequently dependent upon the abuser, the risk in telling is often too great.

The Child Sexual Abuse Accommodation Syndrome

Ronald Summit (1983) defined the Child Sexual Abuse Accommodation Syndrome. This
describes why in cases of incest it is so difficult for the family to take action to protect
the child. In cases of intrafamilial sexual abuse, protecting the family is more important
than protecting the child. A child who tells a "stranger " is viewed as having betrayed the
family and so, such children are frequently pressured to recant.

There is a secondary trauma in being discovered. Normal coping behaviour is to tell a

parent or sibling when someone is hurting them. In the case of sexual abuse within the
family, the child is often accused of lying, manipulating or imagining by the parents,
courts and even therapists. The child is then driven deeper into self-blame, alienation
and revictimisation.

There are five aspects of the accommodation syndrome: -

1. Secrecy –
" Don't tell anybody. They won't believe you anyway"
2. Helplessness –
Disbelief by adult caretakers increases the child’s helplessness.
3. Entrapment and Accommodation –
If the child does not receive immediate protective intervention, the only healthy
option is for the child to accept the situation in order to survive.
4. Delayed, unconvincing disclosure-.
Most ongoing abuse is never disclosed, it comes from conflict, accidental discovery
or community education efforts. Authorities often cannot believe that a truthful child
would tolerate incest without immediately reporting.
5. Retraction –
Since the child has learned to accept secrecy and helplessness, the child is likely to
retract their statement. Beneath the child 's anger is the obligation to preserve the
family.

It is very important that the professional understand the accommodation syndrome in

order to dispel myths about how quickly children should report sexual abuse. Children
want to be loved and they want to preserve the family. The effect of prolonged sexual
abuse is that the child believes on some level that she has provoked the encounters with
the family member, and that by learning to be "good" she can gain the acceptance that
all children crave. Consequently, she loses hope of the abuse ever stopping - she is
helpless, hopeless and isolated - and instead turns her energies towards surviving an
abusive situation and attempting to satisfy the needs that all children have for love,
appreciation and survival.

1.6 MEDIATORS IN THE EFFECTS OF CHILD SEXUAL ABUSE

There are a number of factors which mediate the impact of the abuse upon the child

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Gil (1991) organises the factors as follows: -

1) Age of the child at the time of the abuse. The younger the child, the more vulnerable
the child is to damage. Gil states that childhood trauma is the most damaging to
younger children because "uncontrollable terrifying experiences may have their most
profound effects when the central nervous system and cognitive functions have not yet
fully matured, leading to a global impairment."

2) Chronicity
The longer the abuse lasts, the greater the effect upon the child. With an extended
period of time, the child's sense of vulnerability and helplessness can increase. The
child will then utilise defense mechanisms such as dissociation which will become
problematic later in life.

3) Severity
The greater the violence or the more extensive the genital contact, such as penetration,
the greater the psychological impact upon the child.

4) Relationship to the Offender

The closer the relationship between the offender and the child, the greater the resultant
trauma. The child who is abused by a person outside the home is able to keep the
trauma outside the home and turn to their family for support. When a child is abused by
a family member, the child learns that the person who is supposed to protect and love
them is the person who also hurts them.

5) Level of Threats
The presence of threats may produce generalised anxiety, and fear in the child
potentially worsens the negative impact of the trauma.

6) Emotional Climate of the Child's Family

Families where incest occur are characterised by severe family disorganisation, poor
communication and co-operation, and having very rigid hierarchies.

7) Mental and Emotional Health of the Child

The child who has good psychological health prior to the abuse is better protected
against the damaging effects of the abuse.

8) The Guilt that the Child Experiences

If the child experiences some pleasure during the sexual abuse or feels responsible for
causing the abuse, he or she will be more likely to experience guilt. The experience of
guilt about sexual abuse is associated with greater negative psychological impact.

9) The Sex of the Victim

Male victims manifest more long-term problems and greater psychological than female
victims.

10) Parental Response to the Child's Victimization

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The non-abusive parent plays an essential role in healing the child. The child's recovery
is improved by a parent who believes the child, and is supportive and reassuring rather
than accusatory. An unsupportive or overactive parent results in greater trauma.

It is important that the parent or family :

a) protect the child from further abuse
b) recognise that the child is telling the truth
c) use friends, institutions (such as churches), and family members for support so that
marital conflict or parent/child conflict is minimised.

1.7 THE FAMILY’S RESPONSE TO SEXUAL ABUSE

a) Impact upon the professional relationship

Families appear to go through fives stages in response to the discovery that a member
of their family has been sexually abused. Professionals need to understand how the
response of the family influences how they present to you and how it affects their ability
to fulfil the demands you make upon them (e.g. to process forms, to visit the hospital
and police stations, to provide detailed information in an interview).

1) Shock/Helplessness – “what is happening?”

2) Denial - “It did not happen”

“She would have told me”
“I did not notice any change”

3) Anger – “Who did it, I will kill them!”

“Why did he do it”

4) Sadness – “Our daughter what will become of her?”

“Can she still get married one day?”

5) Resolution – “We will take the following action.”

a) reporting to police
b) going to hospital
c) getting paid for damages
d) keeping quiet

If a family is in the ANGER stage, they may be more impatient with the pace with which
the case is proceeding and direct their anger toward medical and counselling personnel.
They may even change from one police station to another.

If the family is in the SADNESS stage, they may need a great deal more emotional
support than a professional who is just doing their job can give. Relatives and close
confidants are of help here.

The family may move back and forth between several stages. The family may need help
from medical and counselling personnel regarding what action they should take. The
family will experience a mixture of rage and helplessness which might interfere with their
ability to make decisions. Rather than being impatient with them, help them to discuss

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the choices they have (for example, whether they should fill out a formal police report or
not).

b) Impact upon the family

1. Guilt
The parents feel guilty about what happened.

2. Blame
The parents start blaming themselves about what happened.

In incest cases, siblings will blame the victim for sending the father to jail because she
revealed the incest.

3. Shame
The family is ashamed about what happened, making it difficult especially in incest
cases where the father is the offender. The parents’ believe that if the mother had been
a better wife and parent it would not have happened.

4. Failure as parents
If the abuser is a sibling the parents think they have failed as parents and become
powerless to report the case to police. They may seek traditional assistance for
clarification.

5. Fear
There is fear to know the truth of what happened or who did it for what reason. What
will become of my child. e.g. virginity, pregnancy, and infections.

6. Disruption
Disruption of family unit: (a) Mother is sent away with her daughter. (b) In some cases
parents send back their daughter to the man or boyfriend to face further abuse and
pregnancy. (c) The parents are afraid that they are going to be charged with child
neglect. (d) The child is moved away from home to go and stay with relative or social
services take the child to a place of safety.

7. Social - There is fear of stigmatisation on the part of the parents and the child.

8. Economic
Removal of the breadwinner will threaten the family’s economic stability.

9. Status
The child will experience lowered self-esteem especially when the offender is verbally or
physically threatening.

10. Impact upon the Marital Relationship

The father blames the mother for what happened since it is the mother’s duty to take
care of her children. The father may feel ashamed and increase his drinking, which may
lead to unsafe sexual practices.

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The father will send the girl back to the boyfriend. If the mother objects, saying their
daughter is too young, both mother and daughter will be sent away.

11. Gender Inequalities

Perpetrators who are 14, 15, and 16 who sexually abuse girls are set free but the girls
are harassed by the perpetrator, other boys in the community, and the parents
themselves. There is a need for both parents to counsel both male and female children
about proper behaviour, not the girl child only.

Boy child is being groomed to be a rapist from childhood because of saying the girls are
to blame and males can have sex with anybody they choose. This attitude encourages
sexual abuse.

12. Education
The girl is taken out of school because the father will be concerned that after
experiencing sex the girl will not be able to concentrate upon her studies.

The daughter may be forced to marry at a young age.

13. Isolation
In incest cases, the extended family will isolate the family in which the abuse occurred.
They blame her for sending their relative to jail. At social gatherings of the extended
family the victim’s family is excluded.

c) Impact on the child

Children at different ages have different emotional needs. If we understand what a child
needs emotionally for their healthy development then we can assist in the healing
process. Understanding the emotional needs of children helps us to understand what
behaviours, sometimes distressing to parents, they normally might engage in to satisfy
these emotional needs. Children also have fears at particular ages and they behave in
ways to avoid these fears coming into fruition. For example, the emotional needs of a 12
- 18 year old are to have more freedom, to find their own values as compared to their
parents values, and to discover a direction to their future life. The expected behaviours
to satisfy those needs would be rebellion or rejection of parental values, defiance,
idealism, and experimentation with drugs or sex. They behave in this way to avoid their
worst fear: that peers won’t accept them.

In situations where the child is traumatised, they may experience their emotional needs
as more immediate and pressing and seek to remedy their situation by showing even
greater extremes of expected behaviours. An adolescent who has been sexually abused
may have lost faith in adults and therefore will seek with greater immediacy to satisfy
their needs for more freedom and a direction to their future life. As a result, the expected
behaviours of rebellion and defiance may appear in a more extreme form of running
away and destructive behaviours toward themselves and others.

NEEDS AND DEEDS OF CHILDREN

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Age Needs Deeds/expected Worst fears

behaviours
0-1 year Love Soiling That I will starve
Security Crying
Physical contact Irritability
Bonding
1-5 years Approval Temper tantrums That my parents will leave me
Attention Disobedience- test
Safe boundaries/support boundaries
Opportunities to explore Fears (dark, animals)
Independence Hyperactivity
Bedwetting/soiling
Eating problems
Masturbation/sex play
6-12 years Mastery Perseverance Annihilation
Recognition Competition “Leopard will get me”
Fighting with friends & I’ll never be any good at
siblings anything
Appearance Adult witchcraft
Instant gratification
12-18 years More freedom Rebellion/rejection of That peers won’t accept me
Direction to future life parental values That I’ll be like my parents
Finding own values Defiance That I won’t be successful in
compared to parents Idealism/new ideas life
values Experimentation
(drugs, crimes)

d) The entwined relationships between the child, the family and the professional
In cases of sexual abuse, the child becomes the focus of both the professional's and
family's attentions. However, attention needs to be paid to the role of all three players:
the professional, the child, and the family. The family goes through several stages
in their response to sexual abuse. Their response affects the family's reaction to the
professional, the family's reaction to the child, and these two reactions influence the
professional's reaction to the child and family. Consequently, all three parties are
intertwined and each group's response to the other needs to be taken into account.

1.8 THE CONTEXT IN WHICH THE CHILD LIVES

To work effectively with sexually abused children, it is important to recognise the many
levels of society which influence their lives. All of these societal influences can either
hurt or help the child in their recovery from sexual abuse. They can act as stress factors
or resilience factors for the child.

The child does not stand-alone. The family, which includes extended family members,
is an important influence in helping the child to recover from the effects of the sexual
abuse. To do this effectively, the family must be supported so it can support the child.
Useful questions to consider are as follows:
Is the family supportive or do they blame the child?
How is the marriage coping with the stress that the disclosure of sexual abuse brings -
are the parents blaming one another for what has happened? Are the parents through
their actions demonstrating values which give women autonomy and power over the
direction of their own lives?

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The community which consists of the neighbours, the school, the church, and the
child's peer group can provide stability for both the child and family during stressful
times. For the child, the stability of the school environment and regular contact with
peers helps to limit the destructive effects of the shame and social isolation associated
with sexual abuse. In many situations, a peer is the first person that an abused child will
speak to about what has happened. For the parents, the church or other community
group provides much needed support.

The culture and religion of the family determines how they will view the sexual abuse
of their child. The cultural and religious values will influence whether the child now
views herself positively or negatively.

There is also the government system, consisting of the police, the hospital, and the
courts, which provide a response to sexual abuse. Depending upon the speed and
humanity with which the wheels of justice turn, this process can either be a hurtful or
helpful experience for the child and family. Important questions to consider: How many
times has the child had to tell their story? How have government staff received the
child,
with acceptance, rejection, or sexual advances? How do the conditions of working in
the
government system influence the care which a child receives?

Economic and social policy directly affects children. For example, a poor economy will
result in girls having to leave school because their parents cannot afford school fees.
Remaining at home unsupervised then leaves them more vulnerable to sexual abuse.

To understand children, it is important to know all the levels of society with which they
interact. By taking into account all the various levels of society and its positive or
negative impact upon the child, one can better guide both the child and parents in
directions that are positive and healing rather than destructive.

1.9 A MULTI-SECTORAL APPROACH TO CHILD ABUSE

Suspicion of sexual abuse

If you suspect sexual abuse, you can make a report to the police who will then
investigate the case further. There is no mandatory reporting in most Southern African
countries which means that there is no legal requirement to report if a person suspects
sexual abuse.

When a child is sexually abused

The parents or guardians should take the following actions:
a) Report to the police
b) Take the child to the hospital for a medical examination
c) Contact social welfare if the child is at risk of further abuse and needs to be
removed from the home.
d) Attend court (the police will inform the parents of the court date).

The Victim Friendly System was established to provide support for vulnerable witnesses,
specifically women and children. There are now Victim Friendly Court Systems in South

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Africa and Zimbabwe. Changes that have been instituted in the law are that children do
not have to directly face their abusers in court but may be interviewed in specially
designed playrooms; and that an Intermediary specially trained in speaking to children
will take the questions from the court and phrase them in non-intimidating, age
appropriate language to the child.

Functions of the sectors involved:

POLICE - To take down the details of the case and commence investigations
regarding the perpetrator. It is important that if the perpetrator has
committed other sex crimes in other districts there be a way of
coordinating information.

HOSPITAL - Medical personnel examine the child and provide a medical affidavit to be
used in court proceedings. If available, counselling staff provide crisis
intervention services to lessen the child’s trauma and reduce the
destructive impact of the trauma upon the family.

COURTS - Prosecutor assures that all necessary investigations have been

completed and that the child witness has been properly prepared to
testify in court. The prosecutor and the magistrate assure that the court
proceedings are as humane and as rapid as possible.

SOCIAL
WELFARE - If a place of safety is needed for the child, the social welfare officer
secures it. The officer also writes probation reports for juvenile offenders.

COUNSELLING
AGENCIES - Provide crisis intervention and long-term counselling services to the child
and family in order to minimise the impact of the sexual abuse.

Challenges for multi-sectoral approaches to child abuse

Advocacy:
Question - Who pushes the system when a case is delayed at the police or court level?
Solution - An ombudsman or representative from the police, social welfare, or courts is
tasked with keeping the child’s interests at heart. Their office would investigate all
delays.

Coordination between Sectors:

Question - How do you maintain clear, rapid, communication between sectors who are
following a case when the relevant offices are widely dispersed throughout an area?
Solution - Monthly meetings of an implementation committee are held involving front-
line staff from all sectors who deal with sexual abuse cases. In these meetings they
clarify various miscommunications and delays regarding specific cases.

Reduction of Interviews:
Question - A child can be interviewed up to eight times from when they first report at
the police station until they finish with the courts, since each sector insists upon
interviewing the child. How can the number of interviews be reduced?

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Solution - Form interviewing teams based at the hospital consisting of a doctor,

counsellor and social worker (if needed) and form a second interview team at the police
station consisting of a police officer and social worker.

Reduction of the Number of Cases Thrown Out of Court:

Question - Many cases of children, especially those aged seven and under, are thrown
out of court because of their inability to testify in the courtroom setting. Yet in a
counselling setting the children have spoken freely. What can you do?
Solution - Create a child friendly court where the child is properly prepared by the
prosecutor as to what to expect in court proceedings. Have the child interviewed in a
room apart from the court but connected by closed circuit TV so that the court can
witness the proceedings. The questions from the court would come through an
intermediary, connected by earphones to the court, who would then put the questions to
the child in a non-threatening, age appropriate manner. Also have a support person
present in the room to relax the child - this could be a parent, relative, or social worker.
Have the counsellor and prosecutor work together to prepare the child to be the best
possible witness.

2. COUNSELLING SKILLS AND TREATMENT STRATEGIES

2.1 HOW CHILDREN COMMUNICATE

Children speak three languages: -

The language of the body

The language of the body is the first language that children learn. It is a baby squirming
when it is uncomfortable. It is children complaining of headaches or stomachaches
when they are tense. Our bodies express our emotional condition, often when our minds
are unaware of what we are truly feeling.

The language of play

The language of play is when a child shows us rather that tells us how they are
experiencing in their lives. This is a natural form of communication for children from pre-
school through primary school age. An example would be when a child comes home
from school and pays with their blocks. The child makes the red block their teacher and
the yellow block their friend. Using the red block, the child has the teacher tell the friend
what a good student he is.

Play is theatre - watching a child play is like watching a wonderful drama. Observe how
the child's play begins and ends. This will inform you whether the story the child has
shown you has progressed forward by the end of their meeting with you.

The playroom is also your doctor's kit. Observe how the children use their toys. Become
aware of which toys or materials children use to tell their story. If you can understand
how the playroom materials and certain activities bring up specific topics and emotions
in children, then you can expand the skills you bring to counselling. (See "Use of the
Playroom")

Be aware of how children of different ages view you. This will influence what the child
brings to their relationships with you. For example, if a young child relates to you as an

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uncle or auntie they will trust you quickly and be comfortable in the relationship. While if
the child views you as a doctor, they will be fearful.

If you know how children play and learn about the world at different ages, then you can
use many options in your counselling to communicate. Watch what sense the children
use in their play. Watch how they handle strong feelings in their play. In your playroom,
you can use several activities - imaginative play, physical play and board games. Watch
how children use them and the effect it has upon them emotionally.

Spoken Language
This is the last language that children learn. They learn that words can represent things
- words are symbolic. They learn that words have the power to express the child's
desires and can make people do things. Because this is new language for young
children, they may use words incorrectly to express their feelings, their desires, or what
they have seen. For example a child may say, "I hate you" when what they mean is " I
am angry at you". Or when a child has a new experience, they may only be able to
describe it in terms of previous experiences they have had. A five-year-old child
described her sexual abuse as saying that the gardener had "picked her with a thorn".

Speaking the Languages of Children

It is necessary to integrate these three languages into your communication with the
child. The child often tells their story non-verbally thorough their play, their behaviour,
and their body language. Through observing the languages of children and how children
express their meaning, the professional can learn about what has happened to the child.

When working with children, you are working with their HEADS, HEARTS AND
IMAGINATIONS. The role of the counsellor is to both communicate and listen to the
child on the levels of intellect (oh yes I understand this), emotions (my heart is so
confused) and the part of us which speaks often frightening truths, our fantasies (I want
to eat you up!).

When you enter the child's world, it is important to follow the child's lead. This allows the
child to lead you where you need to go. In daily life, it is the adult who leads. In
counselling, it is important that the counsellor follow the child.

What to do when a child will not talk

It is important to acknowledge to the child that they may have good reasons for keeping
quiet and then to take action to answer the child's fears to their satisfaction. For
example, if the child is fearful of punishment then the professional should sit down
briefly with the child and parent, and discuss this fear and obtain assurances from the
parent that there will be no punishment.

There are many things that a professional can do to assist a child in communicating.
Below is a checklist: -

• Take time to get to know the child. Use games, activities, or easy conversation to
help the child relax.

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• Show an interest in the child as a person. Where do they go to school, who are their
friends, what sports do they like? etc.

• Assure that a support person (a relative or trained professional in working with

children) can relax the child, and can communicate this to the child.
Note - Both the verbal and non-verbal language of the support person should be
observed to assure that it supports and relaxes the child.

• Create trust by informing the child of what will be happening and informing them of
your role.

• Check if the child is hungry or thirsty.

• Show that you respect and accept the child. Do not be judgmental or critical.
• After you have relaxed the child and given information about what will happen, look
at them carefully to see if they are still nervous or scared. If they are showing a high
level of anxiety, see if you can guess what questions they might have and answer
them or ask the support person for help.

• Your questions may evoke subjects that the child cannot easily talk about. Ask
questions that are easier to respond to. Once rapport is again established, return to
be more difficult questions.

• Remove obstacles in verbal communication by being patient and providing the child
with other means of expression such as writing their answers, drawing what
happened etc.

It is recommended that when a child comes to you, you offer them all of the possible
languages in which to communicate i.e. play, spoken language etc. Many children speak
and play at the same time. For older children, the counsellor needs to evaluate in which
language the child communicates best. Some may prefer spoken language, others may
prefer writing or even play.

2.2 HOW CHIILDREN COMMUNICATE ABOUT SEXUAL ABUSE

Body Language
Since the first language that children speak is body language, watch for behavioural
indicators that show that the child is either distressed or physically injured. Look
carefully for signs of withdrawal, a painful or odd gait, reluctance or stiffening of the
body when touched, increased activity level, or aggressive behaviour.

The rule of children is “do unto others as has been done unto you”. A child may repeat
with others what exactly was done to them. Unlike sex play, where the actions between
two people are consensual, in this situation one child will force another to participate in
sexual acts. Children do not like being the victims of acts which confuse or hurt them, so
they become the aggressors and do to others what has been done to them.

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The Language of Play

Children ten years and younger usually express themselves most freely through play.
The child can use any object to represent the people involved. A stone might represent
the girl involved, a stick might be her teacher, and small pebbles might be her
classmates.

Spoken Language
When children tell you a story, they are either repeating a story they have heard or the
story represents their experience, often in a disguised form. Children can be afraid or
ashamed of telling the events directly, so they tell the story in a fable form.

The ability of children to relate the story directly is most developed in teenagers because
by then they have a large store of experiences with which to understand events like
sexual abuse. In contrast, young children will use experiences they already know to
describe new experiences, so that their stories might sound odd or unbelievable. Recall
the earlier example where a five-year-old girl said she was pricked by a thorn, when
trying to describe her abuse.

Other Expressive Tools

Children can often use drawings to show what happened to them. Like play, these
drawings can be disguised versions of the event or may directly show what occurred.
The younger the child, the more likely they will illustrate the event in a disguised form.

Poetry, written stories, or drama are also useful ways to encourage a child to express
themselves.

2.3 STRUCTURING THE COUNSELLING ENVIRONMENT

Before the Session

1) Ask yourself, “ what has the client been through before seeing you?” What
professionals have they seen? What do you already know about them - review any
written material.

2) Whom are you going to see? The entire family together? The child, then the
parents?
The parents first?
During the Session

1) Arrange the seats in such a way that eye contact is easily made with each member of
the family. Ideally everyone should be at the same level. No seat should be higher
than another.

2) Decide upon the language to be spoken. Choose the language which is easiest for
the client to communicate in. If in doubt, ask the client.

3) Unless you have met several times with the client previously and know the client
well, do not meet alone with a client. Always have someone in the room with you,
either a colleague or a relative of the client. Meeting alone with a client may raise the
client’s anxiety about being abused again and it may leave the therapist vulnerable
to charges of abuse if no witness is present.

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4) With aggressive clients, have someone present in the room or nearby whom you can
call upon for help. If this is not possible, then sit near the door so that you can leave
easily.

5) Explain the purpose of the interview:

• To hear your thoughts and feelings about what has happened.
• To give you the medical care you need.
• To talk about what has been difficult for you and what your worries are.

6) Hear everyone’s story. Encourage communication. Check your body language so

that you appear receptive to what anyone has to say and show that you will not
judge them.

7) If a child appears anxious or frightened inform them of the basic rule: “No one gets
hurt here. I will not hurt you and I will not allow you to hurt me.”

8) Have toys such as dolls, puzzles, or wire to relax the child.

9) Explain confidentiality:
• To the family: “Your medical exam and test results will be sent to court if you
have made a police report. Otherwise whatever you say stays in this room.”
• To the teen: “Whatever you say stays between us unless you’re suicidal.
Then I’ll inform your parents and the doctor so that we can keep you safe.”

10) Note-taking: Take only brief notes during the session. Do details later.

Closing the Session

11) Discuss fees.

12) Discuss future meetings: when and how often.

2.4 INTERVIEWING SKILLS

To ensure a successful interview the child must feel comfortable in your presence. The
child must trust that: -
• you will not harm them
• you will be supportive of them
• you will look after their basic needs.

Within the first moments of the interview, the child will decide whether he or she will like
the professional and can trust them. Therefore, the skills for building rapport with
children are essential and will in part determine the child’s willingness to reveal their
secret thoughts and feelings.

CHECKLIST: Essentials for Assuring That You Have the Best Rapport with the
Child
1) Has what will be happening to the child been simply and briefly explained to them?
2) Has each professional introduced themselves and what they do?

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3) Have you obtained the parents’ cooperation and explained why you are taking
certain actions?
4) Has the parent given the child permission, either verbally or non-verbally, to
participate in each interview (the police interview, the medical exam, court testimony,
and counselling sessions)?
5) If the child is being seen alone, has the child been shown where the parent is
waiting?
6) If you think the child has traveled from a great distance or has been waiting several
hours ask the child if they are hungry or thirsty and get them what they require. If the
child is hungry or thirsty they will not be able to concentrate in the interview.
7) Does the child need to go to the toilet?
8) Before you begin the interview, are you showing interest in the child and taking time
to JOIN with them? Find out what their interests are and what they like to do.
9) Are you noticing when you are losing rapport with the child and are you making
efforts to renew it? (This will often happen when the child is required to talk or testify
for a long period of time and becomes tired or irritable).

It is important to find a way to establish a relationship with the child through which the
child can communicate to you. Without a relationship, the child has no motivation to tell
you the story of what has happened to them.

It is a useful exercise to be able to answer the following questions before you begin the
interview:
1. How do you make the family/child feel comfortable?

2. How do you explain what the interview will be about and what you do?

3. How do you arrange yourself and the family for the best possible communication

4. Confidentiality – is it within the family or the child/individual?

5. Notetaking – how do you prevent it from blocking communication?

2.5 OBSTACLES ENCOUNTERED IN INTERVIEWING CHILDREN

COMMUNICATION BLOCK #1: LANGUAGE PROBLEMS

It is important to be confident that the child is understanding your questions. Use the
following guidelines:

a) Ask one question at a time, breaking down complicated questions into simple,
individual questions.

b) Keep the language used in questions simple and appropriate for the child’s age.

c) Observe the child’s facial expressions and body language to help to determine if
the child is understanding the question.

d) If you require further clarification, ask the child to repeat back your question.

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COMMUNICATION BLOCK #2: THE ADULT IS NOT ENCOURAGING

COMMUNICATION.

There are actions which adults may take which block communication.
a) Getting upset or emotional
b) Becoming uncomfortable or embarrassed when the child is upset.
c) Verbally or non-verbally indicating criticism or judgement of the child.
d) Talking too much or asking too many questions.

Both the child and the professional are responsible for breakdowns in communication.
The child’s wish to communicate might be hindered by feelings of sadness, distrust or
guilt. The adult might block communication by not taking the time to create rapport with
the child and building a climate of trust and encouragement.

COMMUNICATION BLOCK #3: NON-VERBAL CUES

Children are extremely sensitive to non-verbal cues (body language): it is their first
language. If what you say is contradicted by your tone of voice or your body language
the child will become suspicious. For example, if your voice sounds welcoming to the
child but your body posture is closed and stiff, the child will sense your discomfort.

It is important for the professional to monitor what his or her non-verbal behaviour is
conveying to the child. Be careful not to influence the child non-verbally, through small
gestures or posture, for giving what you think is the "right" answer or rejecting them for
not giving the "expected" answer. Also be aware of unwittingly prejudicing the child by
responding differentially to what they say - for example, by showing greater interest in
sexual or violent material.

COMMUNICATION BLOCK #4: THE CHILD HAS STRONG EMOTIONAL

REACTIONS WHICH PREVENT THEIR COMMUNICATION

Often, we see children who will not speak in an interview. The children often have good
reasons for not speaking to you about what happened to them. Rather than becoming
angry or frustrated, understand what are the reasons behind the child’s inability to
speak. They are as follows:
a) Shame in talking about the sexual abuse.
b) Lack of trust. The child has not time to know the adult professionals involved in
the case.
c) Anger and hostility. The child or teenager has had to tell their story numerous
times. They may have been mistreated by their parents or the professionals
interviewing them.
d) Fear of punishment.
e) Insecurity. The child is in need of a support person to help them. For example,
the young child may need their parent with them rather than a social worker.
f) Rules about talking to adults. There are clear rules regarding which adults a child
can talk to about an incident like rape. A child would not naturally talk to a
Policeman, a prosecutor or an intermediary. Children are also taught to be silent
in the presence of an adult unless given permission to speak.
g) The child may lack the words to describe such an emotional experience, or be
afraid of being overwhelmed by their feelings, especially in front of male
professionals.

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Knowing that these might be some of the reasons for the silence of the child, the
professional can now take actions to remedy the situation as outlined in the section
What to Do When A Child Won’t Talk.

2.6 QUALITIES OF THE COUNSELLOR

The Definition of Counselling
Counselling is a special relationship where the child and the parents have your full
interest and attention. It is a time where the parents and children can tell or show you
anything they wish. The purpose of counselling is to create an environment of trust
where the child and family can learn more about their thoughts, there feelings, and their
life. Through this process, the child or family is able to take action to achieve their goals
or to solve their problems.

To be effective in their work, the counsellor must possess certain qualities.

a) Empathy
To feel what your client is feeling and to be able to express that back to your client. For
example, “I can feel how angry you are right now.”

b) Respect
The client is a person worthy of your attention. Communicate this to them.

c) Genuineness
Be honest with yourself, be aware of your own thoughts and feelings as the client
speaks. Be honest with the client.

d) Acceptance
Accept your client’s culture and beliefs. Accept your client’s problems - do not show
disbelief or shock at their problems. Accept your client’s feelings: allow your client to cry,
be angry, etc

2.7 COUNSELLING SKILLS

Counselling involves listening skills and problem-solving skills.

a) Listening Skills:
These include the skills necessary to demonstrate to your client that you are giving them
full attention and listening carefully.

b) Understanding Skills
These skills demonstrate to the client that you are understanding them. Use the
following techniques to improve your understanding of what your client is saying:

i) Summarising – this technique demonstrates to the client that you have truly
heard and understood them. Every so often while the client is speaking, rephrase
what the client has told you. Then ask the client if this summary is correct.

ii) Clarifying - when you don’t understand what the client is saying, ask them to give
you an example or say “are you saying that (for example) the child deserved to
be beaten?” The client will either agree with your clarification or amend it.

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c) Problem Solving Skills

The client has come to you with a problem. The first step is to help them DEFINE THE
PROBLEM. You are not telling them what the problem is, they are telling you. When you
think you know, summarise it for them and see if they have any corrections. Do not
impose your definition of the problem upon the family.

2.8 A MODEL OF COUNSELLING

When you counsel a person or a family, there are four steps you go through:
(i)Joining (ii) Defining the problems (iii) Widening the view of the problem (iv) Solutions

i) JOINING
This is about creating a relationship with the child or family so that you can
communicate effectively. Joining is necessary if effective counselling is to occur. This
can be done through:

- Introducing yourself as a counsellor

- Greeting the child
- Finding out what the child likes
- Addressing fears the child might have
- Commenting on child's appearance

In "joining" with both the child and the family, the professional takes specific actions to
establish rapport before asking the difficult questions about the sexual abuse. The
professional should "join" with the child in different ways depending upon the child's
developmental stage, as demonstrated in the chart below.

HOW TO JOIN WITH CHILDREN AT CERTAIN DEVELOPMENTAL STAGES

(0 – 18 YEARS OF AGE)

0 – 5 years 6 – 12 years 13 – 18 years

Sit and crouch Identify interests Show interest in the person
(hobbies / games)

Talk to them Praise good points Address them at their own

Pat them Accommodate specific
needs (take shopping)
Praise them
Comment positively on their
Musical game clothing, actions, etc
level: as a child or as an
adult
Invite them to help you with
something

Sing and dance (they will Give them an interesting

join in) magazine and discuss it

Eye contact Comment positively on their

clothing

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ii) DEFINING THE PROBLEM

This step is to help the family define the problem they wish to work on, not the problem
the counsellor thinks they should work on. Some useful questions follow below:

1.What brings you / the family here today?

2. What have you tried in order to solve the problem ( n’angas, friends, relatives, etc)?
3.What have they told you?
4.When did the problem begin? What was going on at the time?
5.How long have you had this problem?
6. What makes the problem better? What makes the problem worse?
7. If you are working with a family, get them to prioritise concerns.
8.What would you like to get from these meetings?

iii) WIDENING THE VIEW OF THE PROBLEM

In this stage, you are enquiring about all the things that might be contributing to the
problem.
Find out what is going well and where the difficulties are in each of the following areas:
a) Home life
b) School life
c) Work life of the parents
d) Marital life of the parents
e) Social life of the child
f) Social life of the parents
g) Physical health of the parents
h) Physical health of the child

iv) SOLUTIONS
What solutions can the family devise to overcome the problem? The above areas that
have contributed to the problem can also contribute to the solution. Ask the following
questions:

a) What changes would you like to see in your life?

b) What could each of you do to help with this problem?
c) What obstacles might prevent you from overcoming the problem?
d) What could you do then?

2.9 PLAY THERAPY

THE LANGUAGE OF CHILDREN

Children speak three languages: the language of the body, the language of play, and
spoken language. The first two languages are their "mother tongue". Before children
can speak, their bodies express their needs and wants. A mother can tell when her child
is uncomfortable, tired, or in plain by looking at her child's body and facial expressions.
Even in adult life, our bodies as we sit at work or school express our level of energy and
attention.

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Through the language of play, a child shows what has happened to them. Playing with
a child is the same as having a conversation with the child, except one is using play
rather than spoken language. As in any conversation, there are three aspects:

a) The Warm-Up (includes greetings)

b) Intimate Conversation
c) Defensive Conversation

In play, time needs to be taken for the warm-up phase. This is where the child will
explore the toys or objects in the playroom or office. The child may jump from toy to toy,
not staying with any activity for very long. During this period, the child is getting to know
the environment and your responses to him or her. Since children are very sensitive to
body language, they are able to pick up cues from your posture and facial expressions.
In this phase, you will encourage the child in whatever they are doing.

It is also useful in the warm-up phase to physically get down to the child's level. If the
child is playing on the floor, and it is culturally accepted, you should join the child there
as well. If the child is initially shy, you can introduce them to the toys in the playroom.
Allow the child to explore on their own for a period of time. During this time quietly
observe the child and occasionally comment positively on what they are doing. When
you think they are comfortable with both the environment and yourself, you can ask the
child "would you like me to play?".

During this phase, the play may be repetitive or imitative of the things the child has been
in their environment.

In the second phase, intimate conversation, the child will begin to show you what is in
their hearts and minds. They will need materials that allow for expression such as paper
and crayons, plasticene, human and animal figures (or objects that can be used to
represent them - they can use plasticene or even bottlecaps to represent figures). You
will simply comment on what you see the child doing. For example, "I see that you are
putting the little girl into that house." While playing, the child will often narrate a story.
When a child plays, they can be gently encouraged by your questions to continue
narrating the story of their play. The questions should not be so many, though, that they
interrupt the flow the child's play.

In this phase, the child will show you what is happening in their life by using toys to
demonstrate various events. The demonstration of these events may not always be
straightforward, but may be in disguised form. Certain objects may represent important
people and events in the child's life. For example, the abuser may be represented by a
snake or lion and victim might be represented by a little girl figure or rabbit. You will
learn the meaning of various objects only as the child narrates their story in detail
through their play.

It is often too dangerous for a child to come directly out and show you the exact person
who abused him or her. It is much safer to disguise the people and actions involved. But
the child wants the message to be understood, otherwise they would not show you
anything.

HOW TO MOVE THE PLAY FORWARD

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When you are stuck or wish to find out more what the child is showing you, do the
following:

a) Point to a figure or object, ask, "Who's this? Tell me about him/her/it.

b) Ask, "What will happen next?"
c) Ask, "I wonder what you would do in this situation?"

Near the end of play after the child has told you the story, you can ask about specific
toys to determine whom they might represent in the child's life. The child may not be
ready to tell you. You will then see defensive play: the child will either remain silent or
the child may rapidly change to another topic of play (this is what adults do when they
change the subject.) You can then gently try to guide the child back to the original topic,
saying, "this may be difficult or even scary to talk about".

There is also defensive conversation where the child does not want to talk about the
thought and feelings that are arising. The professional can recognise this when the child
may have been engaged in an activity for a period of time and will suddenly shift to a
new activity. Or after being in the playroom for a length of time, the child may become
agitated and jump from activity. This is equivalent to adult conversation when the person
changes the subject.

The third language the child learn to speak is spoken language. Until the child is at
least eight-year-old, he or she is still learning the true meaning of words. Because
spoken language is a new language for young children they may use words incorrectly
to express their feelings, desires or what they have seen.

Spending time communicating with children through body language and play will often
yield richer information than only verbally interviewing the child.

2.10 THE USE OF THE PLAYROOM

The toys of the playroom are to illuminate what is the young child's heart and mind.
When a child choose a toy in the playroom, they choose it because it has a meaning for
them - either they will use the toy to imitate something they have seen in real life or they
will use the toy to help show what happened to them, as in the cases of sexually abused
children. Children find it helpful to be able to both show (by using a toy) at the same time
as telling what happened to them.

Basics of the Playroom

Game - useful for getting to know the child and for reducing anxiety. These could
include: -
• drafts
• puzzles
• stories
• bottlecaps
• hangman

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Materials to make objects - useful for making objects that can be used by the child to
show what happened to him/her. The physical activity of making things is also effective
in reducing anxiety. These may include: -
• clay
• building blocks
• yarn/string
• wire
• sticks, seeds, stones, mealie cobs
• paper

2.11 USE OF QUESTIONS

There are three types of questions that encourage the child to speak - closed questions,
multiple choice questions and open questions.

Closed or Yes/No Questions

These are questions that can be answered briefly with a yes or no. Examples may be
"do you go to school?" or "Did he tell you to keep it a secret?" These are the easiest
questions for the child to answer but give the least information. They are used in the
early stages of an interview to help rapport. There are caveats or warnings to consider
in using these questions: -

• They may elicit "social desirability" responses in children. The child may answer yes
because the child thinks a positive response is involved.
• The child may not understand the question and still answer yes.

Multiple Choice Questions

These questions give the child several choices. For example, "Were you wearing your
day clothes or night clothes?" They require more thought than closed questions. There
are several caveats to consider in using these questions: -
Young children have difficulty, especially when several choices are given (it may be
confusing).
• The correct response must be given in the question so that the child is not asked to
choose between two or more incorrect responses.

Open or Focused Questions

These questions require descriptive answers rather that merely a yes or no. Potentially,
they provide more information than closed or multiple choice question. They are used
later in the interview once a relationship with the child has been established. Examples
ate "What things does Mr. Choga do with the family?" " Can you tell us a secret that you
and Mr. Choga have?"

It is best to begin with questions that are not difficult to answer (closed questions) and
then to progress forward to questions that require more detail or are emotionally more
difficult to answer (multiple choice and open questions).

2.12 ASSESSMENT (THE INTAKE INTERVIEW) Versus COUSELLING (THE

FOLLOW-UP INTERVIEW AND BEYOND)

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ASSESSMENT (THE INTAKE INTERVIEW)

In an intake or assessment interview the objective is to impartially gather information
that will guide medical interventions as well as to inform the prosecutor, if required.

Your objective is to evaluate what is necessary for the future treatment plan of the client
and inn situations where the occurrence of abuse is unclear you may be asked to
determine, to the best of your ability, if abuse did occur based upon the psychological
evidence you are collecting.

Since many cases are only seen once, it is useful to also provide counselling in addition
to the assessment. This will require you to evaluate the degree of trauma and to help
reduce it. You can reduce trauma in a child and their family by doing the following: -

• Identifying the feelings of family members and the child (e.g. sadness, anger,
shock, etc) and letting them know that you understand how they are feeling and
that many people in their situation feel exactly the same way.

• Give the family hope for future. Inform the family that there feelings will decrease
with time and that the pain will lessen. They will not forget what happened, but
they will be able to continue with their lives.

Please consult the Intake Interview and The Guide to the Intake Interview in the
Appendix.

FOLLOW-UP INTERVIEW (ASSESSING PROGRESS)

What constitutes a second interview?

After completing the assessment or intake phase the counsellor should prepare a plan
that outlines the goals and objectives of treatment and lists the methods that he/she will
use to address the symptoms of the abuse. Whenever possible, the child and
parents/caretakers should participate in the development of the treatment plan. This
helps them feel a part of the therapeutic plan. Often children and parents are more
willing to participate for the length of time necessary to complete the treatment plan
when they have had a part in clarifying the symptoms and learning about the tasks
necessary to address those symptoms. The treatment plan should be reviewed
periodically and modified when necessary. Again this process should be undertaken
with the help of the child and parents. So the beginning phase of therapy should focus
on establishing trust and rapport, determining the child’s current level of functioning and
coping style, and making therapy useful to the child. The objective of the follow-up
interview is to reduce the degree of trauma.

Evaluate the following:

• What is the degree of crisis/conflict the family is in?

• Is the home/institution environment safe?
• Is there physical/sexual violence towards any member of the family?

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• Is any member suicidal?

If the answer is yes to ANY of the above – then take action immediately.

If the family is presently in your office, do not let them leave until the issue is resolved. If
the problem is beyond your skill level, refer to another agency specialising in the
relevant area (crisis counselling, intensive therapy, etc.)

When you are meeting with the family it is also useful to assess the following
areas: (when you are supervising a case, these are important questions to consider)

1. How is the case progressing?

2. What is the general emotional tone of the family? Is it communicating?
3. Relationship within the family
a. Degree of marital conflict
b. Parent and child conflict
4. Assess which stage the family is in regarding the five stages:
shock, denial, anger, sadness and resolution/action.
5. Find out the role of the extended family. Are they supportive or destructive?
6. Find out how the family wants to resolve the extended family issues.
7. Culture and tradition - how is it influencing the action the family is taking in healing
from the trauma of the sexual abuse?
8. Religion - is this a religious family? What explanation are they giving for why the
sexual abuse occurred? Is it a scientific cultural or religious explanation?
9. Is the child at school? If not, why? How is the child adjusting since the time they
were sexually abused?
10. Legal aspects – how is the case progressing in the courts?
11. What is the resilience of the family? - the capacity not just to survive but thrive in
difficult circumstances.
12. Assess whether the family has a sense of the future e.g. future plans for the girl –
adoption, termination of pregnancy.
14. Ask what the child wants to do when she grows up.
15. Address fears for both parents and child.
16. In an HIV positive child (usually twelve and older) ask how this affects their future
(schooling, friends, marriage, having children, etc.)

Termination of therapy
When to terminate
Sexually abused children suffer a wide variety of symptoms and problems i.e. within the
home and in different institutions. Therefore the criteria for discharging differs from one
child to another. Five general points are essential to meet before the discharge.

1. The abused child must have at least one adult caretaker in the family to whom the
child can talk when he/she is upset about the abuse or any other matters.
2. The child should be able to talk about a range of feelings both in therapy and to
friends. Remember abused children have great difficulty in feeling safe and so
many children hide their feelings to avoid feeling vulnerable or being teased. But this

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avoidance of feelings serves to isolate the child from developing close friendships
which are important to promote healing.
3. Check if the child is doing as well in school and with friends as she/he was prior to
the abuse. The child should be at about the same level of functioning as he or she
was prior to the abuse.
4. The child should not be symptomatic e.g. child should be free of intrusions,
bedwetting, panic attacks, sleep problems and many other symptoms related to
abuse.
5. Family conflict should be resolved.

There should not be premature termination of therapy. Follow-ups should be used at

increasing periods of time (for example, with severely traumatised cases start meeting
every week, then every two weeks, then once a month, and finally once every six
months to determine the client’s progress).

Therapy is one of many important strategies to help sexually abused children move
beyond the role of victim and continue their progress toward positive and productive
adulthood. Therapy with abused children is often demanding and challenging. However,
it offers the immediate reward to the therapist of knowing that he/she is making every
effort to help the child and the family who are struggling to overcome the effects of
abuse. For this reason, therapy is a valuable service and a major contributor to the well
being of sexually abused children and their families.

2.13 WORKING WITH THE FAMILY

In working with the family, you want to encourage a supportive, non-judgmental

environment which allows each family member to heal from the trauma they have
experienced. You want to help each member to develop an understanding of what
happened and how it affected each of them. Most importantly, you want to help the
family to move on to find success and areas of gratification in their future life, rather
than being permanently crushed under the burden of this event.

To do this, one must be aware of several ideas:

1. Obtain each family member’s point of view.

2. Observe who has the authority in the family and who makes the decisions.
3. Observe who is excluded in the family or whose voice is silenced.
4. Observe who gets the most attention and the least attention in the meeting.
5. Observe whose opinion is listened to.
6. Observe who wants you on their side.

Where there are power imbalances, vacate all family members, with the permission of
the authority figure, and speak to the weaker member alone to obtain their point of view.

With children, give them something to play with or draw while you are talking to the
family. Watch their behaviour throughout the meeting. What do they do and at what

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points in the session? Do they stop, listen, try to interrupt? The behaviour of the children
can provide you with valuable information about what might be happening in the family.

2.14 WORKING WITH GROUPS

Essentials of Group Therapy

Group therapy is a forum where certain unique therapeutic experiences are made
possible when persons meet regularly with others who share the same problems but
who do not share a life together.

Objectives:
Among other things, group therapy allows people to see directly that they are not alone
with their problems; it allows them the opportunity to help others and be helped.

It increases each members hope and optimism as others in the group strive to
overcome difficulties similar to his or her own. It provides a sense of belonging to a
special supportive community. It allows new information to emerge that might be more
difficult to disclose in individual or family meetings. Children spontaneously reveal their
concerns in the presence of other children more than in the presence of single adult
therapist or family.

Groups can provide opportunities for practicing more successful interactions and coming
up with solutions on interpersonal problems.

Children will have new ways of thinking, communicating, and acting to prevent further
abuse. This process works to free the child from feelings of inferiority and being
different. Group therapy also frees the child from stigmatisation and other negative
descriptions that often get applied to these children by others and by themselves as a
result of the abuse.

The child may act shy during the interview with mother. The mother and counsellor may
say the child is withdrawn, yet if she is in a group she is an outgoing person with her
peers.

Groups increase understanding, acceptance and rebuild trust.

How to set up a Group

1. Composition of the group: same age, or mixed, same sex or mixed, same problem
or mixed?

2. Membership:
Open: Members join at anytime
Closed: Membership is closed. Members go through with a certain group to the end.

3. Format: Activity oriented or talk oriented.

4. Group size: What is the ideal size for good communication? The more activity
oriented a group is the larger the group size can be. For intensive therapy groups,
using talking only, the ideal size is no larger than seven.

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5. Time limit: What is the best time limit? For intensive psychotherapy groups one to
one and half-hours is optimal. For larger activity oriented groups one to two hours is
optimal.

6. Frequency of sessions: To maintain continuity, at least once or twice a month.

7. Group boundaries:
Can group members visit each other outside the meeting times? For intensive
psychotherapy groups, group members are discouraged from meeting together
outside of group times in the belief that outside discussion about group members
weakens the power of the group when they meet. For support groups, members are
encouraged to visit one another outside of the group.

8. Role of therapist: Directive vs Non-Directive.

Does the therapist set an agenda for the group or allow the group to determine
what they wish to talk about? In-groups that focus upon a specific issue such as
drug abuse or sexual abuse, the therapist may take a leading role in the early
sessions to establish a direction for the group. In activity oriented groups, the
therapist sets the agenda. In-groups using personality exploration as their objective,
group members are encouraged to determine their own agenda.

9. Working with other systems: Does the group interact with other systems like
police, parents, schools and communities? Advocacy groups would interact more
frequently with other systems.

2.15 PREVENTING REVICTIMISATION OF THE CHILD

How do you help the victim to reduce their vulnerability to being abused again?

- environment - makes it safe - remove the child from the situation

- family supervision at home
- re-education of the child who has displayed sexualised behaviours

3. ISSUES FOR THE THERAPIST

3.1 BURNOUT AND EFFECTS ON THE COUNSELLOR

Introduction to the use of self

We need to look carefully at our own feelings and experiences and how they influence
us and how we act on them. Knowing our characteristic responses to abused children
can help us to recognise our own vulnerabilities that may mirror the family dynamics in
the abused child’s family.

- Be aware of personal handicaps

- Blind spots (issues you may have difficulty approaching/discussing)

- As a therapist you are part of the therapeutic system. You may act out family
dynamics. Keep a running internal dialogue like:-

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“What do I feel now”

“Is this experience unusual for me?”
“Am I acting in a way that expresses these feelings?”

Knowing Yourself
Understanding one’s own motives for working with abused children is a vital part of
knowing yourself. Knowing yourself makes it far easier to be honest and straightforward
with children.

Consider
Dreading the appointment
Clock-watching
Mumbling
Experiencing anger/boredom
Aligning with family members
Blaming the client for the problem
Feeling impatient
Lecturing/debating/arguing

Professional Supervision
One of the ways to contain all the feelings which are projected onto counsellors by
children is by having good, professional supervision for counsellors. When we face an
onslaught of emotions and confused, powerful responses which are projected onto us
every day, we can begin to feel powerless, confused, helpless and chaotic. We can feel
like the children we are trying to support. By having a supervisor whom we can trust,
who is willing to hold up a mirror to our own confusions, we can contain our own
emotions and we can ensure that we are not projecting those onto an already confused
child.

To keep our boundaries for our clients we must make sure we know where our own
boundaries are. We must not reflect and repeat the formless and uncontained lives
which many abused children are forced to lead because their families are unable to
“hold things together”. The economic and psychological pressures upon many families
are enormous; it is difficult for many to survive. For us as workers there are pressures of
the organisation as well as personal pressures, and the stress of the work itself. We
must be aware of when we are feeling unfit to work with children and be able to rely on
our supervisors to tell use so, if we cannot see it ourselves.

3.2 LISTENING TO STORIES OF ABUSE

Working with clients who come to you with their stories of sexual abuse can evoke many
different feelings within the therapist. Since the therapist is working with such powerful
feelings, he or she may also experience strong emotional reactions within themselves.

Listed below are some common emotional responses from therapists:

• feeling extremely sorry for or sympathetic with the client

• feeling sexually excited
• feeling very depressed

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• fearing for the welfare of our own children

• shock – can’t help in 1st session need to get over the shock first.
• confused – am I picking up on the client’s feelings?
• disgusted – does client feel same way?

Be aware of your responses. How does your body language change as you hear
these stories? Catch yourself as your body language changes, don’t ignore it.

How to resolve our feelings with actual cases – how do we deal with it?

• taking time out

• acknowledge your feelings, talk to colleagues immediately
• use silence in the session to catch up with your own emotions
• not always useful to hide feelings from client

3.3 THE EFFECT OF YOUR ATTITUDES AND VALUES UPON YOUR WORK

We all have attitudes and values toward:

a) Men/Women
b) Children
c) Sexual Abuse/Sexually explicit material

How do these attitudes affect our work?

Ask yourself the following questions:

a) Men are _________ (fill in the blank)

b) Women are _______(fill in the blank)

c) As a parent I believe children should be________ (fill in the blank)

d) As a professional I believe children should be________(fill in the blank)

e) When people tell me their stories of sexual abuse I sometimes feel _________(fill in
the blank).

It is most interesting to do these exercises as a group.

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What do the descriptive words used to describe men and women imply about your
attitude toward them? Below, are some descriptive words that workshop participants
have used to describe men and women:

MEN ARE WOMEN ARE

• Rude Lovely
• Considerate Slow thinkers
• Cruel Caring
• Immature Explosive
• Caring Dangerous
• Reckless Short-sighted
• Selfish Too sensitive
• Funny Murderers
• Hardworking Jealous
• Oppressive Cruel
What are the differences in what you expect from children as a parent compared to what
you expect from children as a professional? Are these values contradictory? If so, how
do you resolve them in your work?

Some comments from workshop participants follow below:

As a parent I believe children should be:
• loved
• cared for
• respected
• educated
• listened to
• supervised
• guided
• disciplined
• consulted
• obedient

As a counselling professional I want children who come to me to:

• feel at home
• express their feelings
• bring relatives
• be smart and presentable
• be informed about their rights
• be happy
• be motivated

What is the effect upon you in listening to stories of abuse? What does it bring up for
you personally? How does it affect you in your work and in your life at home?

Some comments from workshop participants follow below:

When people tell me their stories of sexual abuse I feel

• disgusted
• depressed

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• angry
• shocked
• hurt
• concerned
• sorry
• down – hearted
• confused
• sad

It is important for the therapist to know how they are affected by the work that they do.
Knowledge is power. Use the knowledge that you acquire from constantly asking
yourself how you are affected by the work you do and it will make you a better therapist
and of greater service to the clients who rely upon you.

Appendix A THE FAMILY SUPPORT CLINIC

INTAKE FORM – SEXUAL ABUSE

Date of Assessment: ……………………… Interview by:…………………………………………………

Name: ………………………………………………………………………………………………………………
Address: …………………………………………………………. Phone:
………………………………………
Sex: ……… Date of Birth: …………………………………….. Age:
………………………………………...
Accompanied by: …………………………………………………………………………………………………..
Referred by: ………………………………………………… Case Docket No: ……………………………...
Educational level
Is the child currently in school:
[] YES Name of school: ………………………………………. Grade / form:……………………………
[] NO If no state why: ………………………………………………………………………………………….
Presenting Problem

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Type of abuse:
……………………………………………………………………………………………………...
Where did the abuse take place:
………………………………………………………………………………………………………………………..
Dates /frequency of abuse: ……………………………………………………………………………………….
Who did the child live with at the time of abuse:
………………………………………………………………………………………………………………………..
Has the child moved [] YES [] NO Where to: …………………………………………………………...
Who discovered the abuse: ……………………………………………………………………………………...
How was the abuse discovered………………………………………………………………………………….
Who did the child tell about the abuse…………………………………………………………………..
………………………………………………………………………………………………………………
Time from first incidence of abuse to discovery: [] 0-24 hours [] 25-48 hours [] 3-7 days
[] 1 week to 1 month [] 2-6 months [] more than 6 months [] more than 1year
[] unknown

Time from discovery of abuse to clinic: [] 0-24 hours [] 25-48 hours [] 3-7 days
[] 1 week to 1 month [] 2-6 months [] more than 6 months [] more than 1 year
[] unknown
Comments (including infections)
………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………
Have there been any changes in the child’s behaviour at home or school since the abuse began?
Yes[] [] No List changes:
………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………
Behavioural Indicators :
[] Aggression [] Running away [] Somatic Symptoms
[] Disrespectful behavior [] Deliberate self harm/suicide [] Substance abuse
[] Sexualised behaviours [] Nightmares [] Lethargy/tiredness
[] Sleep disturbance [] Bedwetting/soiling [] Crying

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[] Eating less/more [] Decline in school performance [] Withdrawal from social / family

group
[] Weight loss/gain [] Fear – people / objects / place [] Compulsive lying

Physical Indicators:
[] Difficulty in walking/sitting [] Bruising or bleeding in external genitalia (vaginal/anal)
[] Pain or itching in genital area [] STI/infections [] Pregnancy

Perpetrator
Perpetrator’s name: ............................................................................. Age:
.................………………...
Marital status of perpetrator: ........................... Perpetrator’s
occupation:................…………………….
Relation of perpetrator to victim:
.................................................................................................…………………
Threats / inducements used:
..........................................................................................................………………..
Violence involved [] YES [] NO (details)
.........................................................................………………..
Has abuser been arrested by police [] YES [] NO
Has abuser been released on bail [] YES [] NO

Knowledge of previous abuse by abuser [] YES [] NO

Specify who was abused …………………………………………………………………………………………

Child’s contact with abuser since reporting [] YES [] NO

Where / effect of contact:
...............................................................................................................………………..
..........................................................................................................................................................……
….
What action is the victim’s family taking ………………………………………………………….…………….
Response of abusers family:
..........................................................................................................…………………………….

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Threats since discovering / reporting the abuse:

............................................................................…………………………………………………..
Is there a prior history of abuse by different perpetrators? Yes No
Frequency……………………………………………………………………..
Ages when it occurred ………………………………………………………
Who (by relation/occupation) ………………………………………………..

Family and Social History

Resides where: ............................... Type of residence ……………………………………………………
Family structure / situation (parents, siblings, loss of relatives, lodgers etc.)
......................……………….
.................................................................................................................................................................
.................................................................................................................................................................
..............
………………………………………………………………………………………………………………………..
.
Genogram:

Employment: Father ................................ Mother ........................... or Guardian ....................

Family dynamics (family response/reactions to the abuse, and effects on
family)...........................………………......................................................................................................
.................................................................................................................................................................
.................................................................................................................................................................
....................
Support (for victims and
family):.............................................................................................……………….

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.................................................................................................................................................................
.......
Are other systems involved: [] Legal resources [] Police [] Institutions
[] Psychiatry [] Other NGO [] Social Welfare [] Court [] N’anga

Clinical Observations (severity of trauma/ appearance/ mood)

Severity of trauma :- 1---------------2----------------------3--------------------------4------------------5
Less Severe Moderate Extremely Severe
………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………
Revictimization: Is it safe for the child to return to their present living environment? [] YES [] NO

Client’s concerns, worries or questions

Are there any worries / concerns you would like to discuss ?
Medical (procedure, infections, HIV etc.):
....................................................................................………………..
.................................................................................................................................................................
.....................................................................................................................................................………
…………
Psychological (effect on the child / family):
..................................................................................………………..........................................................
.................................................................................................................................................................
.............................................................................................…………………………………………………
……………
Legal (what will happen to perpetrator; court procedures etc):
.....................................................……………….......................................................................................
.................................................................................................................................................................
................................................................………………………………………………………………………
…………..
What do you want from today / Any other questions ?:
.................................................................………………………………………………………………………
…

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Treatment Plan (follow up, letters, referrals etc.):

.........................................................................…………………………………………………………………
..
.................................................................................................................................................................
.................................................................................................................................................................
.................................................................................................................................................................
.......................................................………………………………………………………………………………
………………..

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Appendix B
GUIDE TO THE F.S.C. INTAKE FORM

The purpose of the intake interview is to acquire a comprehensive picture of the child’s
life beyond the incident of sexual abuse in order to evaluate both the risk and healing
factors in the child’s life. The intake form is divided into seven main areas of inquiry:

1. Demographic Information
2. Presenting Problem
3. Perpetrator Information
4. Family and Social History
5. Clinical Observations
6. Client Concerns
7. Treatment Plan

Each section will now be summarised. Individual items requiring clarification will be
described in more detail below.

1. DEMOGRAPHIC INFORMATION
This section contains basic background information about the child. It includes items
such as name, address, and educational level of the child.

a. Accompanied by - who came with the child to the hospital (police, relative, etc.).
b. Referred by - who sent the child to the hospital (police, doctor, relative, etc.)
c. Case docket number - what is the police case number, for identification of the case
when dealing with the police.
d. Educational level : if the child is not in school state why - is the child out of school
because the parents have no money, or because the girl is now pregnant, or other
reasons?

2. PRESENTING PROBLEM
This section describes what actually happened to the child as well as any changes in the
child’s behaviour since the abuse began.

a. Type of abuse - describe what happened. Was it vaginal penetration, anal

penetration, insertion of a finger or foreign object into the vagina or anus, oral sex,
fondling of body parts, masturbation, genital exposure by the perpetrator
(exhibitionism), or commercial exploitation for purposes of pornography or
prostitution.

b. Where did the abuse take place - whose home did it occur in, or was it in an open
area, a school, a car, etc.

c. Dates/frequency of abuse - when did the abuse occur? If it occurred on more than
one occasion, give the dates for each time it occurred. List the total number of
incidents of abuse.

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d. Who did the child live with at the time of abuse - was the child living with their
biological family, stepfamily, sibling headed household, a relative (state whom),
friends, etc.

e. How was the abuse discovered - what physical or behavioural indicators indicated to
the caretaker that this child had been abused? For example, did the child have
inflamed private parts, discharge from their private parts, sexualised behaviours or
nightmares. Or perhaps the abuse was discovered because the child told someone.

f. Time from first incidence of abuse to discovery - often there can be a prior history of
abuse before someone actually discovers that a child has been abused. How long
did it take from when the child first remembers being abused until someone
discovered it?

g. Time from discovery of abuse to clinic - once the abuse was discovered how long did
it take the family to come to the clinic? If there was a long delay, enquire the reasons
for this.

h. Comments - some people find it easier to write the whole story of what happened
and then fill in the individual items later. If the child is suffering from any type of
sexually transmitted infection please make a special note of it here.

i. Have their been any changes in the child’s behaviour at home or school since the
abuse began
- since the abuse first began (if there is a prior history of abuse, you are asking
about the time of the first incident) what changes have people noticed in the child’s
behaviour. Talk to people who know the child best.

j. Behavioural and Physical Indicators - once you have heard what the caretakers had
to say about changes they had noticed in the child’s behaviour, review the list of
behavioural and physical indicators to determine if any other indicators were noticed.

i. sexualised behaviours - increased masturbation, attempted intercourse

ii. sleep disturbance - difficulty falling asleep, waking up very early, sleeping too
much
iii. somatic symptoms - headaches, stomach aches
iv. substance abuse - increase in use of alcohol, mbanje, or other drugs
v. lethargy - no energy for chores or interest in anything
vi. withdrawal - does not play or socialize with friends or family
vii. compulsive lying - an increase in lying

3. PERPETRATOR INFORMATION

This section obtains essential information about the perpetrator and the degree of
threats or violence used in order to evaluate the degree to which the child might be
traumatised by the sexual abuse.
a. Relation of perpetrator to victim - is the perpetrator a relative, an immediate family

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Member, a lodger, someone in a position of authority, or a stranger. State the

relationship.

b. Threats/Inducements used - to get the child to consent did the perpetrator either
threaten the child or “bribe” the child? State exactly what was said to threaten or
bribe the child. Also state what threats were used after the abuse was completed to
prevent the child from disclosing the abuse.

c. Knowledge of previous abuse by abuser - has this perpetrator abused any other
children?
Specify who - list the names of the children and contact the police with the
information.

d. Child’s contact with abuser since reporting - has the child either seen or been
spoken to by the abuser since the police report was completed?
Where/Effect of contact - state where the contact occurred (home, school, etc.).
Describe how the child and family reacted to seeing or hearing from the abuser
again.

e. What action is the victim’s family taking - what is the family doing about the abuse of
their child? Are they taking legal action, getting medical treatment, seeing a N’anga,
beating up the abuser, approaching the incident customarily and seeking damages,
etc. Detail the various actions that the family is taking.

f. Response of abuser’s family - what is the abuser’s family doing about the abuse?
Are they threatening the victim’s family, trying to settle it customarily by paying
damages, staying quiet, or some other response? State what the abuser’s family is
doing.

g. Threats since discovering/reporting the abuse - has the abuser or abuser’s family
made any threats to the victim or their family since the abuse was reported? State
who made the threat and exactly what was said or done.

h. Is there a prior history of abuse by different perpetrators - have other individuals also
abused this child?

i. State how many other times the child has been abused (frequency).

ii. State how old the child was each time the abuse occurred or if it occurred
over a period of time, state the age of the child when it began and when it
ended (ages when it occurred).

iii. State who abused the child, naming their relationship to the child (cousin,
uncle, etc.) or occupation that put them in contact with the child (teacher,
policeman, etc.). (Who).

4. FAMILY AND SOCIAL HISTORY

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In this section, the present living arrangement, who has lived and died within the family,
and the family’s response to the abuse is obtained.

a. Type of residence - does the family own their house, are they lodgers, do they live in
farmworker’s accommodation, or is the child in a children’s home, etc. State the
living situation of the family or child.

b. Family structure - state who the client is living with, include extended family and
lodgers if they share the same residence. Also note people who have died within the
family structure.

c. Genogram - diagram who lives in the family and show any divorces or deaths that
have occurred.

d. Family dynamics - how have various family members reacted to the news of the
abuse? What effects has the abuse had upon the family? Note any past or present
domestic violence. What has happened to the child since the abuse was discovered
(has the child been beaten, taken out of school, given away in marriage, abused
again, etc.)? How has the parents’ marriage been affected (has the husband blamed
the wife, has the wife refused to be intimate with the husband, etc.)?

e. Support - the event of sexual abuse can tear a family apart. During this difficult time,
who does each family member turn to for emotional support. State which people or
institutions (church, school) each member of the family uses for support.

5. CLINICAL OBSERVATIONS

In this section the counsellor records their observations of the client’s mental and
physical condition.

a. Severity of trauma - in comparison to other sexually abused children you have

seen, how severely traumatised is this child?

b. Appearance - how does the child look to you? Describe their dress, weight, hygiene,
and general health.

c. Mood - what emotion is the child primarily feeling in the interview (anger, sadness,
fear, etc.). Note if the child’s mood changes during the interview (e.g. the child was
quiet and sad at the start of the interview, but when the mother vacated the child
became very talkative and angry.)

d. Revicitimization - will this child be sexually abused again if he or she returns to their
present living environment?

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6. CLIENT CONCERNS

In this section, any worries or concerns that the client has are noted. These concerns
should be followed up in both the medical and counselling interviews.

a. What do you want from today - what are the client’s expectations in coming to the
clinic? If the counsellor does not satisfy the client’s expectations, the client will not
return for further treatment.

7. TREATMENT PLAN

In this section you will state the actions that you will take to assist the child and family in
healing from the trauma of sexual abuse. State what both the counselling and medical
team will do. Also summarise the important counselling issues to be covered in the
follow-up session, so that any counsellor reviewing your intake notes will know how to
proceed.

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Appendix C

COUNSELLING SKILLS CHECKLIST

A. BACKGROUND

1. What kind of abuse occurred? (Definitions)

2. What can you observe about a child to determine if they have been sexually
abused? (Indicators)
3. How does a child communicate to you that they have been abused (through
body language, through play, through spoken language)? (Communication)
4. What might be the effects of this abuse upon the child? (Effects)
5. What are the family’s responses to sexual abuse? (Responses)
6. Who are the people or institutions that can influence the problem and its solution:
(Context)
7. How does the medical-legal system work – whom should you contact to help
move a case forward? (Sex Abuse and the Law)

B. DOING COUNSELLING

1. Have you JOINED with each family member?

2. Have you created a safe environment where people are free to talk (includes
confidentiality)? (Structuring the Counseling Environment)
3. How are you using the Problem-Solution model?
4. What can the counselor do when they are stuck?
5. What if your client is a danger to themselves or others (includes suicide,
mutilation, and revictimization)? (Crisis Intervention)

C ADVANCED SKILLS
1. What does the counselor do when they are together with a family (includes
getting each member’s point of view, correcting power imbalances, moving the
family toward a solution)?
2. How do you find out the child’s problem (includes the use of play, drawings, and
interview -play therapy)
3. How do you work with the HIV positive child and their family?
4. The follow-up interview: how do you assess progress?
5. How do you help the abused child to reduce their vulnerability to revictimization?

D PROTECTION OF THE COUNSELOR

1. How is the counselor feeling at the end of a difficult case? (How to assess your
energy level.)
2. Supervision and Debriefing

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