Working With Sexually Abused Children
Gregory K. Moffatt, Ph.D.

2013 - Counseling Today, 56, 54-58

Introduction: Mateo* (not his real name), a precocious and delightful little five-year-old boy sat on the floor in my office playroom. Each week in therapy, he routinely played with a small plastic doll and every time, without fail, he placed objects into the doll's mouth. This day, however, he did something more aggressive. He took a Tinker Toy, an apparent phallic symbol, and repeatedly jammed it into the doll's mouth, his eyes wide and face full of rage. "He doesn't want it in his mouth," Mateo said into the air, "but he's going to get it in there anyway!"
Mateo had been sexually violated by a male babysitter several months earlier. I'm confident, in part based on his playroom behavior, that the babysitter forced himself into Mateo's mouth. Fellatio wasn't the only violation forced upon Mateo, but it was the most brutal. Recovery for Mateo would take months.That was more than 25 years ago. He was one of the first seriously abused children to enter my private practice and I've never forgotten him.
Unfortunately, Mateo was the first in a very long line of children I've seen over a nearly three-decade career. Working with these children has taught me many things. While some children progress very quickly, I've learned to have patience with the children whose recoverycomes more slowly. I've learned to be careful in taking notes, how to spot parents/guardians who are trying to manipulate me, and how to prepare for court. Working with physically and sexually abused children isn't easy and there are many things about therapy with this population that I wish I'd been taught in graduate school, but instead I had to learn through experience.

Complications When Working With The Sexually Abused Child: Confidentiality and mandated reporting: Fortunately for me, Mateo's perpetrator had already been arrested and child protective services had been involved before he came to see me. But limits of confidentiality due to mandated reporting still remained. My records could still have been subpoenaed and I could have been called to court. I had to be very careful. I make the limits of confidentiality clear to parents and guardians of my clients, but it is challenging to help the child understand mandated reporting, court-ordered disclosure, or other similar issues that would require me to talk about his personal issues with others. Even further complicating this puzzle is the inclusion of guardians ad litem and social workers to whom I occasionally must also report. Yet it is imperative that the child understand that I cannot always keep his secrets. When I see that his is about to disclose something I might have to share with someone else, I often have to remind him about my obligations. "Remember I told you that sometimes I have to tell people what you tell me?" I remind him. "I think you might be about to tell me something like that so I wanted to remind you so you could choose whether or not you want to say it."

Even when I don't have to worry about disclosing issues to the court or to child protective services, I still must contend with the many people in the child's life who want to know what is going on in therapy. Mateo was routinely brought to therapy by his biological mother, but he was also brought in by a grandmother, an aunt, and his father. Access to a child's records/therapy progress legally and ethically belong to the custodial parent(s), but this can be a very challenging dilemma. Grandparents, step-parents, siblings, step-siblings, live-in-girl/boyfriends, and even neighbors are among the people who have brought children to my clinical office or who have called and requested information about a session. Maintaining confidentiality for my the child, but also partnering with parents, guardians, or caregivers, can be challenging. I want and need parental cooperation, but I am also bound by ethics and by the law regarding what I can say to whom. One child, whom I saw off and on for almost a decade, was not in the legal custody of his grandparents for most of that time, even though the child had lived with them since birth and his mother was almost completely absent from his life. So should I have taken the grandparents' payment, but refused to discuss therapy with them? I don't think so.

Hidden Agendas: Working with abused children is complicated enough by itself. We have to consider developmental issues at the time of the trauma, who the perpetrator was, whether it was a single event or ritualistic abuse, the health of the child's support system/family, and the coping skills and problem-solving set the child has at his/her disposal. But that isn't all we have to think about as therapists. Parents, especially those who are either divorcing or battling for custody, often have hidden agendas when they bring their children to me. "I hope my husband didn't do anything to my daughter," I've often heard, "but I'm worried that he might have abused her." Sometimes this comes from parents who really do have this concern. Other times, the parent is attempting to play me, hoping I'll find something that might imply abuse, so that he or she can use that information against the spouse in a custody hearing.Other times, the parent's sole purpose was to have the accusation/intervention on record for when she took her custody request to a judge. My intake forms specifically ask about marital status and I am very cautious when divorcing parents bring "concerns" of potential abuse that just happened to pop up after a decision to divorce.

Assessment versus Therapy: As a young therapist, it took me a while to realize there was a difference between assessment and therapy. In those days, I approached all children the same. I was originally trained as a Person-Centered therapist and I had very little preparation in my graduate work in assessment. I was taughtthat what happened outside my office shouldn't didn't concern me. My job was to help the child achieve healing, soI began therapy with the first session. Imagine my embarrassment the first time I encountered the court system without a clear assessment.

The assessment is the first step in determining, as a mandated reporter, if I need to call child protective services. I have to address all evidence that points toward abuse. I also have to address all evidence that points away from it, as well. If I am called into court, I can be certain a competent attorney will leave no stone unturned to exonerate his/her client. Likewise, I don't want an innocent person going to jail because I didn't do a thorough assessment.
If a case has already entered the court system or been adjudicated, as was true for Mateo, I can relax a little and move more quickly into therapy, but assessment is still important. I have to address developmental issues. Understanding the child's social, physical, emotional, and cognitive development plays a key role in interpreting the child's behavior. A symptom that may look like sexual abuse at one developmental age may not be at another and vise versa. For example, very young children rarely make up stories about sexual abuse. They may be coached into saying things that imply sexual abuse, but they almost never spontaneously make up explicit stories of sexual maltreatment. On the other hand, prepubescent or pubescent children might. They have the cognitive ability to know about sex, its meanings, and to use such skills to deliberately hurt a foster parent, guardian, or parent. Developmental age, coping strategies, and problem-solving abilities have to be noted before I can set forth an appropriate treatment plan.

Evidence-based therapy: In the early 80's, nobody talked about evidence-based theory. It was assumed that if one was good enough to be recognized by the court as an expert witness, one must know what he/she is talking about. No more. Whether I am assessing a child or doing therapy, the processes have to be based on something other than "I think it works." I resisted this transition at first. Afterall, I'd worked with hundreds of children. Hadn't I seen their progress? But now I understand much better the importance of evidenced-based approaches. Whether I am assessing the child or engaging in therapy, it is my responsibility to use approaches that are shown to be valid rather than simply doing what feels right to me. Not only is this more defensible in court, but it is the ethically appropriate thing to do.

Preparing For Court: When I began working with children shortly after leaving graduate school, it was believed that court testimony could further traumatize a child. Therapists, lawyers, and judges alike worked hard to prevent the need for the child to appear in the courtroom. But research, as well as my own experience, has proven those ideas to be flawed. Court can be traumatizing, but more often than not, children are empowered by the opportunity to go to court. They can fearlessly sit in a witness box, testify in their own, childlike language, and leave the courtroom feeling as though they have taken control of their lives. Defense attorneys are reluctant to badger young children and their testimonies can be powerful. Therapeutically, it is equally powerful when a child faces his perpetrator and comes away knowing the perpetrator is going to jail.

Preparing a child for court often involves setting up my office as a courtroom. Children usually know nothing of judges, juries, court recorders, or attorneys. We practice playing court in different roles; thus, teaching the child the various roles people play in court, what to expect, and the role-playing de-mystifies the courtroom. While I often work with the child's attorney as we prepare for court, I cannot prepare the child's answers to likely questions. But I can prepare the child for the questions he or she might expect. "Just tell the truth and answer the questions," I routinely say. "You are not in trouble, but the judge needs to hear from you."

Prior to court, case notes need to be reviewed. Anything that will be used in depositions or provided to the court needs to be clear, concise, and in objective, clinical language. I generally avoid writing anything that I don't need to write down. If it isn't written down it cannot be subpoenaed. For my own testimony in court or depositions, one rule I live by comes from that old line in Dragnet - just the facts. While I have my own agenda and hopes for the outcome of trial, the courtroom is no place for grandstanding, soap boxes, or emotion. I answer questions as concisely as I can, I don't speculate, and I never volunteer information. Even though it sometimes fails, I trust the legal system to do its job and I do mine.

Staying Healthy When Working With Sexually Abused Children: The hardest part of working with abused children, at least for me, is not the sad stories. I've heard them a thousand times and a precious little face is attached to each story. But rather than wearing me down, working with these children is empowering for me. I am helping to make their lives better. I also cope with working with traumatized children by helping to empower them. I teach them skills they need to survive their troubled lives. I help them find ways to solve their problems and I help their parents work with them more effectively. What is hardest for me is when I am totally defeated by the court, social services, or the parents of the children I work with. When I've exhausted all of my resources and can do more, I am most discouraged. At times like these I simply have to remember the sad truth that I cannot save everyone.

In order to help the children in my practice, I have to take care of myself. It is imperative to maintain a good diet, exercise regularly, and get enough rest. I cannot be what my children need me to be if I'm tired, lethargic, or burned out. I find plenty of time to play and to disengage from life at the office. I take care of my health, I find time to laugh, refocus on the "normal" world, and I don't let myself become jaded. I recognize that there are thousands of wonderful parents in the world. I can separate myself from my work because I've learned to put my work into compartments that I can easily open and close at will.

I have resisted texting, giving out my personal cell phone number, and social media. I have to disengage from people with some regularity or I can't rest. When I am at home watching a movie or reading a book, I am fully at home. I am not like so many of my colleagues who feel the need to check email every five minutes or to look at every text message that chimes in, no matter what activity, meal, or conversation it might interrupt. Our culture has made almost any trivial communication an emergency that demands immediate attention. Emergencies happen, but they are relatively rare. When real emergencies happen, I am assessable, but otherwise, my time away from the office is for me and my family.

Conclusion: Children like Mateo are the reason I chose counseling with children as my career path. During my residency and internships, I sat with adults, many of them in their fifties and sixties, while they shared unresolved traumas dating back to childhood. I thought it was tragic that decades earlier their lives had been set on a path that permanently transformed the careers they would choose, who they would marry, and how they would approach life. For almost all of them, no one was there to help them at the time of the trauma. If they had received intervention those many years earlier, their lives would have turned out very differently. My hope for children like Mateo is that the timethey spend together with me will address issues that, left untreated, could lead to years of dysfunctional relationships and unhealthy habits.
There is nothing more satisfying than working with a child like Mateo. Boys and girls bring their stories to me day after day. They come into my office the first time broken and fragmented. But when they leave they are new creatures and I can have confidence that even though their experiences will always remain with them, they will not be in a counselor's office forty years in the future, crying because of the abuse they suffered. That is something we can take care of now and that I why I do what I do.