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Integrating cognitive behavioral and humanistic approaches
Response: CBT and Humanism
357
Response Paper
Areas for Additional A s s e s s m e n t
Integrating Cognitive Behavioral and Humanistic Approaches
YAN, a 12-year-old boy with a substantiated history of sexual abuse by his biological father, presented with significant posttraumatic stress symptoms, depressive symptoms, sexualized behaviors, and oppositional and aggressive behaviors. He had previously been in therapy for 1 year, although the specific nature of the previous treatment is unclear. The biological parents were divorced when Ryan was 4 years old. He currently resides with his mother, stepfather, and 3-year-old half-brother, Michael. Ryan has no contact with his biological father, who was indicted for the sexual abuse, pled guilty to endangering the welfare of a minor, and entered counseling of an unspecified nature.
From the case description (see Deblinger & Hall, p. 346--350, this issue), data collection from psychometric instruments was thorough: Ryan completed the CDI, STAIC, and TSC-C, and his mother completed the CBCL, BDI, and PERQ. Nonetheless, in light of Ryan's significant sexualized behaviors and preoccupation, I would also have the mother complete the Child Sexual Behavior Inventory (Friedrich et al., 1992) to further assess this problem area. Moreover, given the mother's and stepfather's negative perceptions of Ryan and, in particular, Ryan's conflict with the stepfather, I would request that both parents complete the Parental Support Questionnaire (Mannarino & Cohen, 1996) to assess their level of support of Ryan and to assess their perceptions of responsibility related to the abuse. I would also desire more extensive information about the father's abuse of Ryan. What was the extent of the sexual assaults? Was there any penetration? Was there force or a threat of force? Were rewards promised or provided for participation? Additionally, since some boys with a history of sexual abuse by a male develop concerns about gender identity, I would want to know whether this is an ongoing issue for Ryan. I would also seek more history regarding the nature of Ryan's relationship with his biological father prior to the sexual abuse and during the time that the abuse was occurring. It would be helpful as well to better understand why Ryan is currently afraid to see his father and how the mother would feel if Ryan and his biological father were to reinitiate contact. All of this information could be acquired via additional interviewing with Ryan and his mother. Finally, I would want additional information about the previous treatment that Ryan received. What was the theoretical orientation of the therapy? Did Ryan develop a positive relationship with the therapist? What were the specific treatment goals? Were any of these accomplished? Was the family involved in this previous treatment? This information would be helpful in understanding what types of interventions had been tried previously, with what success, and whether any specific problem areas had not been addressed.
Diagnosis
Case Conceptualization
Axis I: posttraumatic stress disorder; major depressive disorder; rule out a disruptive behavior disorder.
A few recent studies have demonstrated the efficacy of trauma-focused CBT in treating sexually abused children (Cohen & Mannarino, 1996a; Cohen & Mannarino, 1998a; Deblinger, Lippman, & Steer, 1996). These investigations have shown that in addition to providing direct treatment to the child, it is very important to include the nonoffending parent(s) in the treatment process. Integrating the basic elements of a humanistic ap-
A n t h o n y R M a n n a r i n o a n d J u d i t h A. C o h e n M C P - H a h n e m a n n University, School of Medicine This response to the case of Ryan integrates the basic elements of a humanistic approach with trauma-focused cognitive behavior therapy (CBT). Within a humanistic perspective, a trusting therapeutic relationship, a safe and secure therapeutic environment, and unconditional positive regard and respectfrom the therapist are emphasized as important factors in contributing to a positive outcome for a child sexual abuse victim and his family. Additionally, a number of CBT interventions are reviewed, including psychoeducation and behavioral contingencies related to inappropriate sexual behaviors, cognitive reframing for both the child and parents to address selfblame for the abuse and other inappropriate attributions and distorted cognitions, gradual exposurefor the child, and behavior management with parents. Family treatment is also described in terms of its importance in helping Ryan and his family recoverfrom the sexual abuse trauma and other related events.
Presenting Problems
Cognitive and Behavioral Practice 7, 357-361, 2000 1077-7229/00/357-36151.00/0 Copyright © 2000 by Association for Advancement of Behavior Therapy. All rights of reproduction in any form reserved.
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Mannarino & Cohen proach with trauma-focused CBT has significant merit. The humanistic approach emphasizes the importance of a trusting relationship between the patient and therapist, providing a safe environment for the patient to express and explore his or her emotional concerns, and a basic respect for the patient as a human being capable of growth. As is typically true with victims of sexual abuse, Ryan was assaulted by someone he knew, his biological father. Given that this victimization was a betrayal of the trust that most children have in their parents, it is not surprising that Ryan endorsed a number of issues on the CAPS indicative of reduced interpersonal trust, including that people he trusts have hurt him. Humanistic principles would suggest that a trusting relationship between Ryan and his therapist would be beneficial in helping him to overcome the previous traumatic betrayal. Despite the increased recognition of the frequency of child sexual abuse in our society, disclosing a victimization experience often brings much embarrassment and shame. The humanistic emphasis on a safe and secure therapeutic environment is therefore essential if a child victim is going to be successful in talking about his or her thoughts and feelings about what occurred. Ryan's statement that he "let Dad do the bad thing" reflects his shame and sense of responsibility related to the abuse. It is therefore critical for the therapist to create a safe, nurturing therapeutic environment for Ryan to discuss these painful feelings and receive the unconditional positive regard and respect that are at the heart of the humanistic model. It should also be noted that Ryan's mother expressed a number of emotional reactions to Ryan's abuse on the PERQ, including guilt, responsibility, and fears about Ryan's future. The trust and safety of a warm therapeutic relationship would also be beneficial to her in addressing and resolving these very difficult feelings. With the humanistic model as a foundation for treatment, there are a number of cognitive and behavioral issues in Ryan's case that can be conceptualized from a CBT framework. Ryan's sense of responsibility for the abuse and for "everything I put my mom through" are distorted cognitions, as is his mother's self-blame for what occurred. Additionally, Ryan's intrusive thoughts, nightmares, and other posttraumatic stress symptoms are clearly related to the abusive experience and can be directly addressed through CBT interventions. Ryan's significant behavior problems, including aggressive behaviors at school and sexualized behaviors, are frequent sequelae of sexual abuse and are responsive to behavioral strategies (Cohen & Mannarino, 1996a). Although Ryan's fighting at school may have multiple origins, it is essential that these behaviors be addressed to ensure that he remains on track in meeting the critical developmental task of attaining school success. There are two other notable areas of concern in
Ryan's case. First, because Ryan has threatened suicide, there are concerns about his safety that need to be considered regardless of therapeutic modality or framework. Second, abuse-related issues and Ryan's behavior problems have contributed to significant family distress such that Ryan's half-brother Michael is perceived much more positively than Ryan by both parents. Also, Ryan's mother feels that she may need to choose between her husband and Ryan because of the intense conflict in their relationship. Blaming and stigmatizing the victim are common reactions in a family in which sexual abuse has occurred and must be addressed as part of the ongoing treatment.
T r e a t m e n t Plan High-Priority Issues The first session would include Ryan, his mother, and stepfather in order to discuss specific problems to address in treatment and to solicit their participation in identifying reasonable treatment goals. I would recommend individual treatment for Ryan, adjunctive parent counseling, and a few family sessions. This first meeting would also involve obtaining the parents' informed consent to proceed with these interventions and to explain the limits of confidentiality to all parties. In particular, it would be critical for Ryan to understand that any concerns about his safety because of suicidal ideation would be shared with his parents. Indeed, addressing the issue of suicidality would be at the top of Ryan's treatment plan. Specifically, I would expect Ryan to agree to a no-suicide contract, which would entail his telling someone he trusts if he is thinking about hurting himself and is in danger. Ryan and his parents would be informed that his safety would always be the number-one priority. In this regard, problem-solving interventions could be used with Ryan to help him develop adaptive coping skills in order to prevent fleeting suicidal thoughts from becoming more serious. Also, the parents would be instructed to take appropriate safety precautions at home, including locking up medications and making it difficult for Ryan to access sharp objects, particularly during periods when Ryan's safety is a genuine concern. The second priority on Ryan's treatment plan would be his sexualized behaviors. In this regard, it would be explained to Ryan and his parents that these behaviors are probably related to the sexual abuse. Regardless of their origin, Ryan and his parents would need to understand that sexualized behaviors are potentially dangerous for both Ryan and other children and that they cannot be tolerated. The parents would be instructed to set firm, but not punitive, limits on these behaviors, with appropriate positive consequences for healthy affectionate behaviors and negative contingencies for inappropriate sexual
Response: CBT and Humanism behaviors. Also, until this problem has been resolved, it would be recommended to the parents that Ryan not be permitted to babysit Michael and that they not be allowed to be alone together in the bedroom or bathroom. Within the CBT model, psychoeducational interventions would be used in the first two or three individual treatment sessions with Ryan to help him understand that sexual concerns and preoccupation are common sequelae after sexual abuse, that sexual feelings are normal for a child his age, but that sexual behaviors could be dangerous for him or others. The development of better problemsolving skills would be beneficial in helping Ryan to respond to sexual feelings in a more adaptive and developmentally appropriate manner. These sexualized behaviors would be monitored throughout treatment and would always be specifically addressed if they recur. Individual Treatment
During the initial two to three individual treatment sessions with Ryan, a major focus, consistent with humanistic principles, would be on establishing a trusting therapeutic alliance. I believe that addressing issues of suicidality and sexualized behaviors from the outset will help to facilitate the development of trust as Ryan would see that someone is very concerned about his safety. Also, in order to further enhance Ryan's sense of trust and safety, I would permit him to determine how long the first few individual sessions would last and what issues would be discussed. Conveying unconditional positive regard to Ryan could be mediated by my interest in and understanding of what parts of his life (e.g., school, sports, friends, etc.) are important to him and communicating respect and genuine caring for who he really is. A number of CBT interventions are essential to Ryan's individual treatment. Psychoeducation would be used to provide him information about the numbers of children who are sexually abused in this country and the different kinds of emotional and behavioral reactions that children have to victimization. The primary goal would be to normalize Ryan's response to this trauma. Additionally, cognitive refraining would be used to address Ryan's inappropriate attributions (i.e., self-blame) for the abuse and associated events. The objective would be to help Ryan develop appropriate attributions about the victimization and also prevent the development of a general attributional style of self-blame for negative events. It would also be important to discuss normal sexual development with Ryan, particularly to help him understand that although his evolving sexual interests may be normal, specific sexualized behaviors are clearly inappropriate. Relaxation training would be helpful in reducing Ryan's anxiety and in providing him with an active coping method to deal with other stressful events. In the CBT model, exposure is defined as the child di-
rectly discussing the traumatic event, with the goal being desensitization to the details of what actually occurred. Although I would encourage Ryan to talk about the sexual abuse, I would adopt a more humanistic approach in which the focus would be on Ryan's feelings, not on eliciting more details. In this regard, I would encourage Ryan to discuss his feelings about the abuse, the perpetrator, and any associated legal proceedings, and also his feelings about his current family situation, including the conflict with his stepfather and that Michael is perceived in a more favorable light by the parents. Within a safe, therapeutic environment, Ryan would hopefully be able to express and resolve his feelings of shame, guilt, and betrayal, and his low self-esteem. The key therapeutic interventions here would be empathy, support, and genuine respect for Ryan's ability to share his feelings. I would allow Ryan to discuss these feelings at his own pace, but it has been my clinical experience that many children Ryan's age are able to do so in 12 to 14 sessions of treatment. Counseling With Parents
Adjunctive counseling with the parents would be a critical component of Ryan's treatment. In fact, I would see the mother as frequently as I would Ryan and invite the stepfather to participate in sessions as well. Previous research has demonstrated a relationship between parents resolving their emotional distress in response to their child's abuse disclosure and a decrease in the child's symptoms at the end of treatment (Cohen & Mannarino, 1996b). Furthermore, the parents' ability to provide support for their abused child has been shown to correlate with improvement in the child's adjustment 6 and 12 months after treatment has concluded (Cohen & Mannarino, 1998b). Fortunately, an integrated approach that includes humanistic and CBT interventions fits well with helping the parents of an abused child to resolve their own issues related to the abuse and to encourage them to be supportive of their child. Ryan's mother has felt very upset about the abuse, feels that she should have been able to prevent it from occurring, feels guilty that she did not know about it sooner, and worries how Ryan will be affected in the future by the abuse experience. Consistent with a humanistic model, a safe therapeutic environment with a trusted therapist would hopefully enable Ryan's mother to express the guilt, shame, and fears that she has developed related to Ryan's abuse. In fact, it has been our clinical experience that whereas abused children are frequently reluctant to discuss abuse-related issues, their parents are typically quite open and welcome the opportunity to do so. Humanistic interventions of support, encouragement, and empathy encourage these parents to express their feelings and move toward resolution. Also, as the parents receive emotional support, they are better able to
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Mannarino & Cohen provide support for their abused child. Parallel to the child's individual treatment, the emphasis here would be on the parents' feelings about abuse-related issues and not the details of the actual abusive experience, unless the parents specifically want to address the latter issue. Interwoven with the humanistic approach would be trauma-focused CBT interventions. Through psychoeducation, Ryan's parents would receive information about the different kinds of emotional and behavioral reactions of both abused children and their parents to the victimization experience. The major goal would be to normalize both Ryan's and the parents' response to this trauma. Also, similar to Ryan's individual treatment, cognitive reframing would be used to address the mother's sense of responsibility related to the abuse and to help her to develop more appropriate attributions. Her ability to achieve this goal would hopefully help relieve her own emotional distress and enable her to be more emotionally available to Ryan. It has been our clinical experience that the parents of traumatized children can become overprotective a n d / o r overly permissive. The development of these parental styles may stem from parental guilt about the trauma, worry that something "bad" could again happen, or feeling that the child has already "been through enough." Parents may then be reluctant to permit the abused child to have normal developmental experiences or to set appropriate limits on unacceptable behaviors. With respect to Ryan, he has clearly been exhibiting problematic behaviors, including fighting at school and sexualized behaviors. The CBT intervention of behavior management would be used with the parents to help them to develop successful strategies of addressing these problems. In particular, it would be important for Ryan's parents to learn that setting limits on inappropriate sexual behaviors would not make him feel ashamed about his sexual development (as some parents believe) but would help him distinguish between acceptable and unacceptable sexual behaviors and make it less likely that he would make the transition from being a victim to someone who perpetrates inappropriate sexual behaviors against younger children.
Family Treatment Family sessions with Ryan, his mother, and stepfather would certainly be necessary to address the conflict between Ryan and his stepfather and Mother's perception that she is in the "middle." One source of conflict may be that the parents have stigmatized Ryan (perhaps inadvertently) for the sexual abuse and this adversely affects their ongoing interactions with and expectations of him. Also, given that Michael is the stepfather's biological child, this may favorably bias his perception of Michael at Ryan's expense. In addition to addressing these issues, it
would be important to identify this family's strengths and to recognize their resilience in response to many stressors. Building open communication styles between family members and developing effective conflict-resolution strategies would hopefully enable Ryan's family to better cope with day-to-day problems. A more detailed description of some of the cognitive behavioral interventions suggested here can be found in Deblinger and Heflin's (1996) recent book on the treatment of sexually abused children and their nonoffending parents.
Adjunctive Interventions Given that Ryan has a major depressive disorder, it would be important to consider pharmacologic interventions if he does not respond to treatment. In this regard, if there is not significant improvement on depressive symptomatology or if suicidal ideation becomes more pervasive, I would recommend a psychiatric evaluation to assess whether a trial of antidepressant medication would be appropriate. Prognosis I believe that the prognosis for Ryan is good. Research has demonstrated the efficacy of CBT interventions with child sexual abuse victims. The treatment plan presented here incorporates both the CBT model and key elements from the humanistic approach. In particular, the development of a trusting therapeutic relationship will hopefully help Ryan to overcome the reduced interpersonal trust that he and many sexual abuse victims experience, which will likely enhance his responsiveness to the therapy experience. Given Ryan's presenting problems, I would anticipate that treatment could be completed in 15 to 20 sessions. I believe that the major obstacles to successful treatment for Ryan would be the existing conflict between Ryan and his stepfather and the negative perception that the parents generally have of Ryan. Accordingly, sessions with the parents and the family would be critical in addressing these issues in order to achieve a positive outcome.
References Cohen,J. A., & Mannarino, A. P. (1996a). A treatment outcome study for sexually abused preschool children: Initial findings. Journal of the American Academy of Child and Adolescent Psychiatry, 35, 42-50. Cohen, J. A., & Mannarino, A. P. (1996b). Factors that mediate treatment outcome of sexually abused preschool children. Journal of the American Academy of Child and Adolescent Psychiatry, 35, 14021410. Cohen, J. A., & Mannarino, A. R (1998a). Interventions for sexually abused children: Initial treatment outcome findings. Child Maltreatment, 3, 17-26. Cohen, J. A., & Mannarino, A. E (1998b). Factors that mediate treatment outcome of sexually abused preschool children: Six and
Response: Family Systems and CBT twelve month follow-up.Journal of the American Academy of Child and AdolescentPsychiatry, 37, 44-51. Deblinger, E., Lippman, J., & Steer, R. (1996). Sexually abused children suffering posttramnatic stress symptolns: Initial treatment outcome findings. Child Maltreatment, 1, 310-321. Deblinger, E., & Herin, A. H. (1996). Treatingsexually abused children and their nonoffendingparents: A cognitive behavioral approach. Newbury Park, CA: Sage Publications. Friedrich, W. N., Grambsch, E, Damon, L., Hewitt, S. K., Koverola, C., Lang, R., Wolfe, V., & Broughton, D. (1992). The Child Sexual Behavior Inventory: Normative and clinical comparisons. PsychologicalAssessment, 4, 303-311. Mannarino, A. E, & Cohen, J. A. (1996). Family-related variables and psychologicalsymptom formation in sexually abused girls.Journal of Child Sexual Abuse, 5, 105-120. Address correspondence to Anthony Mannarino, Ph.D., Allegheny General Hospital, Department of Psychiatry, 4 Allegheny Center, Pittsburgh, PA 15212. Received: November1, 1999 Accepted: December3, 1999
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Presenting Problems YAN, a 12-year-old boy with a history of sexual abuse, presents with symptoms of both disruptive and affective/anxiety symptom clusters. With respect to the former, Ryan has been fighting with peers, arguing with teachers, and exhibiting truancy. Similarly, oppositional and disrespectful behavior toward adults has been observed at home. He has been acting out sexually by grabbing other children's genitals and exhibiting other overt sexualized behavior. With respect to the affective/anxiety (internalizing) disorder symptom cluster, Ryan is exhibiting difficulty with sleeping, depressed mood, sense of pessimistic future, suicidal ideation, irritability, hypervigilance, attention/concentration, intrusive recollections of abuse, avoidance of trauma-related stimuli (internal and external), distrust of others/interpersonal difficulties with peers and adults and academics.
DSM-IV
ResponsePaper Integration of Family and Cognitive Behavioral Therapy for Treating Sexually Abused Children J a n Faust N o v a Southeastern University This paper demonstrates the application and integration of family systems therapy and cognitive behavioral therapy for the treatment of symptomatic children with histories of sexual abuse. This is achieved via the case of Ryan, a 12-year-old boy who had been sexually abused by two family members and who was experiencing affective/ anxiety symptoms and acting-out behavior problems. While this paper provides a theoretical rationale and comprehensive treatment plan, additional details of specific treatment interventions, from both treatment modalities, are delineated. From the family systems perspective, an emphasis is placed upon the discussion of realignment of family structure and changing familial communication patterns (including messages about safety, protection, and validation of children's experiences). From the cognitive behavioral paradigm, exposure therapy and cognitive restructuring are accentuated. Finally, the importance of the integration of both modalities without violating the theoretical assumptions of either is highlighted. Cognitive and Behavioral Practice 7, 361-368, 2000 1077-7229/00/361-36851.00/0 Copyright © 2000 by Association for Advancement of Behavior Therapy. All rights of reproduction in any form reserved.
Diagnosis
Axis I 309.81: posttraumatic stress disorder 296.22: major depressive episode-chronic, moderate 313.81: oppositional defiant disorder Axis II V71.09: no diagnosis Axis III None Axis IV Problems with primary support group (child abuse, family dysfunction) Educational problems (academic, peer, teacher) Axis V GAF = 50 (current)
A s s e s s m e n t Plan The assessment profile presented for Ryan is comprehensive. However, it may be useful to include measures that focus directly on the family and parenting. The Family Environment Scale (Moos & Moos, 1984), while widely used in research, can be used clinically to highlight strengths and weaknesses of family interaction and functioning. Parents* and child should complete these independently. Further, the Five Minute Speech Sample *Throughout the text, "parents" refers to Ryan's biological mother and stepfather.
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Response Paper
Areas for Additional A s s e s s m e n t
Integrating Cognitive Behavioral and Humanistic Approaches
YAN, a 12-year-old boy with a substantiated history of sexual abuse by his biological father, presented with significant posttraumatic stress symptoms, depressive symptoms, sexualized behaviors, and oppositional and aggressive behaviors. He had previously been in therapy for 1 year, although the specific nature of the previous treatment is unclear. The biological parents were divorced when Ryan was 4 years old. He currently resides with his mother, stepfather, and 3-year-old half-brother, Michael. Ryan has no contact with his biological father, who was indicted for the sexual abuse, pled guilty to endangering the welfare of a minor, and entered counseling of an unspecified nature.
From the case description (see Deblinger & Hall, p. 346--350, this issue), data collection from psychometric instruments was thorough: Ryan completed the CDI, STAIC, and TSC-C, and his mother completed the CBCL, BDI, and PERQ. Nonetheless, in light of Ryan's significant sexualized behaviors and preoccupation, I would also have the mother complete the Child Sexual Behavior Inventory (Friedrich et al., 1992) to further assess this problem area. Moreover, given the mother's and stepfather's negative perceptions of Ryan and, in particular, Ryan's conflict with the stepfather, I would request that both parents complete the Parental Support Questionnaire (Mannarino & Cohen, 1996) to assess their level of support of Ryan and to assess their perceptions of responsibility related to the abuse. I would also desire more extensive information about the father's abuse of Ryan. What was the extent of the sexual assaults? Was there any penetration? Was there force or a threat of force? Were rewards promised or provided for participation? Additionally, since some boys with a history of sexual abuse by a male develop concerns about gender identity, I would want to know whether this is an ongoing issue for Ryan. I would also seek more history regarding the nature of Ryan's relationship with his biological father prior to the sexual abuse and during the time that the abuse was occurring. It would be helpful as well to better understand why Ryan is currently afraid to see his father and how the mother would feel if Ryan and his biological father were to reinitiate contact. All of this information could be acquired via additional interviewing with Ryan and his mother. Finally, I would want additional information about the previous treatment that Ryan received. What was the theoretical orientation of the therapy? Did Ryan develop a positive relationship with the therapist? What were the specific treatment goals? Were any of these accomplished? Was the family involved in this previous treatment? This information would be helpful in understanding what types of interventions had been tried previously, with what success, and whether any specific problem areas had not been addressed.
Diagnosis
Case Conceptualization
Axis I: posttraumatic stress disorder; major depressive disorder; rule out a disruptive behavior disorder.
A few recent studies have demonstrated the efficacy of trauma-focused CBT in treating sexually abused children (Cohen & Mannarino, 1996a; Cohen & Mannarino, 1998a; Deblinger, Lippman, & Steer, 1996). These investigations have shown that in addition to providing direct treatment to the child, it is very important to include the nonoffending parent(s) in the treatment process. Integrating the basic elements of a humanistic ap-
A n t h o n y R M a n n a r i n o a n d J u d i t h A. C o h e n M C P - H a h n e m a n n University, School of Medicine This response to the case of Ryan integrates the basic elements of a humanistic approach with trauma-focused cognitive behavior therapy (CBT). Within a humanistic perspective, a trusting therapeutic relationship, a safe and secure therapeutic environment, and unconditional positive regard and respectfrom the therapist are emphasized as important factors in contributing to a positive outcome for a child sexual abuse victim and his family. Additionally, a number of CBT interventions are reviewed, including psychoeducation and behavioral contingencies related to inappropriate sexual behaviors, cognitive reframing for both the child and parents to address selfblame for the abuse and other inappropriate attributions and distorted cognitions, gradual exposurefor the child, and behavior management with parents. Family treatment is also described in terms of its importance in helping Ryan and his family recoverfrom the sexual abuse trauma and other related events.
Presenting Problems
Cognitive and Behavioral Practice 7, 357-361, 2000 1077-7229/00/357-36151.00/0 Copyright © 2000 by Association for Advancement of Behavior Therapy. All rights of reproduction in any form reserved.
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Mannarino & Cohen proach with trauma-focused CBT has significant merit. The humanistic approach emphasizes the importance of a trusting relationship between the patient and therapist, providing a safe environment for the patient to express and explore his or her emotional concerns, and a basic respect for the patient as a human being capable of growth. As is typically true with victims of sexual abuse, Ryan was assaulted by someone he knew, his biological father. Given that this victimization was a betrayal of the trust that most children have in their parents, it is not surprising that Ryan endorsed a number of issues on the CAPS indicative of reduced interpersonal trust, including that people he trusts have hurt him. Humanistic principles would suggest that a trusting relationship between Ryan and his therapist would be beneficial in helping him to overcome the previous traumatic betrayal. Despite the increased recognition of the frequency of child sexual abuse in our society, disclosing a victimization experience often brings much embarrassment and shame. The humanistic emphasis on a safe and secure therapeutic environment is therefore essential if a child victim is going to be successful in talking about his or her thoughts and feelings about what occurred. Ryan's statement that he "let Dad do the bad thing" reflects his shame and sense of responsibility related to the abuse. It is therefore critical for the therapist to create a safe, nurturing therapeutic environment for Ryan to discuss these painful feelings and receive the unconditional positive regard and respect that are at the heart of the humanistic model. It should also be noted that Ryan's mother expressed a number of emotional reactions to Ryan's abuse on the PERQ, including guilt, responsibility, and fears about Ryan's future. The trust and safety of a warm therapeutic relationship would also be beneficial to her in addressing and resolving these very difficult feelings. With the humanistic model as a foundation for treatment, there are a number of cognitive and behavioral issues in Ryan's case that can be conceptualized from a CBT framework. Ryan's sense of responsibility for the abuse and for "everything I put my mom through" are distorted cognitions, as is his mother's self-blame for what occurred. Additionally, Ryan's intrusive thoughts, nightmares, and other posttraumatic stress symptoms are clearly related to the abusive experience and can be directly addressed through CBT interventions. Ryan's significant behavior problems, including aggressive behaviors at school and sexualized behaviors, are frequent sequelae of sexual abuse and are responsive to behavioral strategies (Cohen & Mannarino, 1996a). Although Ryan's fighting at school may have multiple origins, it is essential that these behaviors be addressed to ensure that he remains on track in meeting the critical developmental task of attaining school success. There are two other notable areas of concern in
Ryan's case. First, because Ryan has threatened suicide, there are concerns about his safety that need to be considered regardless of therapeutic modality or framework. Second, abuse-related issues and Ryan's behavior problems have contributed to significant family distress such that Ryan's half-brother Michael is perceived much more positively than Ryan by both parents. Also, Ryan's mother feels that she may need to choose between her husband and Ryan because of the intense conflict in their relationship. Blaming and stigmatizing the victim are common reactions in a family in which sexual abuse has occurred and must be addressed as part of the ongoing treatment.
T r e a t m e n t Plan High-Priority Issues The first session would include Ryan, his mother, and stepfather in order to discuss specific problems to address in treatment and to solicit their participation in identifying reasonable treatment goals. I would recommend individual treatment for Ryan, adjunctive parent counseling, and a few family sessions. This first meeting would also involve obtaining the parents' informed consent to proceed with these interventions and to explain the limits of confidentiality to all parties. In particular, it would be critical for Ryan to understand that any concerns about his safety because of suicidal ideation would be shared with his parents. Indeed, addressing the issue of suicidality would be at the top of Ryan's treatment plan. Specifically, I would expect Ryan to agree to a no-suicide contract, which would entail his telling someone he trusts if he is thinking about hurting himself and is in danger. Ryan and his parents would be informed that his safety would always be the number-one priority. In this regard, problem-solving interventions could be used with Ryan to help him develop adaptive coping skills in order to prevent fleeting suicidal thoughts from becoming more serious. Also, the parents would be instructed to take appropriate safety precautions at home, including locking up medications and making it difficult for Ryan to access sharp objects, particularly during periods when Ryan's safety is a genuine concern. The second priority on Ryan's treatment plan would be his sexualized behaviors. In this regard, it would be explained to Ryan and his parents that these behaviors are probably related to the sexual abuse. Regardless of their origin, Ryan and his parents would need to understand that sexualized behaviors are potentially dangerous for both Ryan and other children and that they cannot be tolerated. The parents would be instructed to set firm, but not punitive, limits on these behaviors, with appropriate positive consequences for healthy affectionate behaviors and negative contingencies for inappropriate sexual
Response: CBT and Humanism behaviors. Also, until this problem has been resolved, it would be recommended to the parents that Ryan not be permitted to babysit Michael and that they not be allowed to be alone together in the bedroom or bathroom. Within the CBT model, psychoeducational interventions would be used in the first two or three individual treatment sessions with Ryan to help him understand that sexual concerns and preoccupation are common sequelae after sexual abuse, that sexual feelings are normal for a child his age, but that sexual behaviors could be dangerous for him or others. The development of better problemsolving skills would be beneficial in helping Ryan to respond to sexual feelings in a more adaptive and developmentally appropriate manner. These sexualized behaviors would be monitored throughout treatment and would always be specifically addressed if they recur. Individual Treatment
During the initial two to three individual treatment sessions with Ryan, a major focus, consistent with humanistic principles, would be on establishing a trusting therapeutic alliance. I believe that addressing issues of suicidality and sexualized behaviors from the outset will help to facilitate the development of trust as Ryan would see that someone is very concerned about his safety. Also, in order to further enhance Ryan's sense of trust and safety, I would permit him to determine how long the first few individual sessions would last and what issues would be discussed. Conveying unconditional positive regard to Ryan could be mediated by my interest in and understanding of what parts of his life (e.g., school, sports, friends, etc.) are important to him and communicating respect and genuine caring for who he really is. A number of CBT interventions are essential to Ryan's individual treatment. Psychoeducation would be used to provide him information about the numbers of children who are sexually abused in this country and the different kinds of emotional and behavioral reactions that children have to victimization. The primary goal would be to normalize Ryan's response to this trauma. Additionally, cognitive refraining would be used to address Ryan's inappropriate attributions (i.e., self-blame) for the abuse and associated events. The objective would be to help Ryan develop appropriate attributions about the victimization and also prevent the development of a general attributional style of self-blame for negative events. It would also be important to discuss normal sexual development with Ryan, particularly to help him understand that although his evolving sexual interests may be normal, specific sexualized behaviors are clearly inappropriate. Relaxation training would be helpful in reducing Ryan's anxiety and in providing him with an active coping method to deal with other stressful events. In the CBT model, exposure is defined as the child di-
rectly discussing the traumatic event, with the goal being desensitization to the details of what actually occurred. Although I would encourage Ryan to talk about the sexual abuse, I would adopt a more humanistic approach in which the focus would be on Ryan's feelings, not on eliciting more details. In this regard, I would encourage Ryan to discuss his feelings about the abuse, the perpetrator, and any associated legal proceedings, and also his feelings about his current family situation, including the conflict with his stepfather and that Michael is perceived in a more favorable light by the parents. Within a safe, therapeutic environment, Ryan would hopefully be able to express and resolve his feelings of shame, guilt, and betrayal, and his low self-esteem. The key therapeutic interventions here would be empathy, support, and genuine respect for Ryan's ability to share his feelings. I would allow Ryan to discuss these feelings at his own pace, but it has been my clinical experience that many children Ryan's age are able to do so in 12 to 14 sessions of treatment. Counseling With Parents
Adjunctive counseling with the parents would be a critical component of Ryan's treatment. In fact, I would see the mother as frequently as I would Ryan and invite the stepfather to participate in sessions as well. Previous research has demonstrated a relationship between parents resolving their emotional distress in response to their child's abuse disclosure and a decrease in the child's symptoms at the end of treatment (Cohen & Mannarino, 1996b). Furthermore, the parents' ability to provide support for their abused child has been shown to correlate with improvement in the child's adjustment 6 and 12 months after treatment has concluded (Cohen & Mannarino, 1998b). Fortunately, an integrated approach that includes humanistic and CBT interventions fits well with helping the parents of an abused child to resolve their own issues related to the abuse and to encourage them to be supportive of their child. Ryan's mother has felt very upset about the abuse, feels that she should have been able to prevent it from occurring, feels guilty that she did not know about it sooner, and worries how Ryan will be affected in the future by the abuse experience. Consistent with a humanistic model, a safe therapeutic environment with a trusted therapist would hopefully enable Ryan's mother to express the guilt, shame, and fears that she has developed related to Ryan's abuse. In fact, it has been our clinical experience that whereas abused children are frequently reluctant to discuss abuse-related issues, their parents are typically quite open and welcome the opportunity to do so. Humanistic interventions of support, encouragement, and empathy encourage these parents to express their feelings and move toward resolution. Also, as the parents receive emotional support, they are better able to
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Mannarino & Cohen provide support for their abused child. Parallel to the child's individual treatment, the emphasis here would be on the parents' feelings about abuse-related issues and not the details of the actual abusive experience, unless the parents specifically want to address the latter issue. Interwoven with the humanistic approach would be trauma-focused CBT interventions. Through psychoeducation, Ryan's parents would receive information about the different kinds of emotional and behavioral reactions of both abused children and their parents to the victimization experience. The major goal would be to normalize both Ryan's and the parents' response to this trauma. Also, similar to Ryan's individual treatment, cognitive reframing would be used to address the mother's sense of responsibility related to the abuse and to help her to develop more appropriate attributions. Her ability to achieve this goal would hopefully help relieve her own emotional distress and enable her to be more emotionally available to Ryan. It has been our clinical experience that the parents of traumatized children can become overprotective a n d / o r overly permissive. The development of these parental styles may stem from parental guilt about the trauma, worry that something "bad" could again happen, or feeling that the child has already "been through enough." Parents may then be reluctant to permit the abused child to have normal developmental experiences or to set appropriate limits on unacceptable behaviors. With respect to Ryan, he has clearly been exhibiting problematic behaviors, including fighting at school and sexualized behaviors. The CBT intervention of behavior management would be used with the parents to help them to develop successful strategies of addressing these problems. In particular, it would be important for Ryan's parents to learn that setting limits on inappropriate sexual behaviors would not make him feel ashamed about his sexual development (as some parents believe) but would help him distinguish between acceptable and unacceptable sexual behaviors and make it less likely that he would make the transition from being a victim to someone who perpetrates inappropriate sexual behaviors against younger children.
Family Treatment Family sessions with Ryan, his mother, and stepfather would certainly be necessary to address the conflict between Ryan and his stepfather and Mother's perception that she is in the "middle." One source of conflict may be that the parents have stigmatized Ryan (perhaps inadvertently) for the sexual abuse and this adversely affects their ongoing interactions with and expectations of him. Also, given that Michael is the stepfather's biological child, this may favorably bias his perception of Michael at Ryan's expense. In addition to addressing these issues, it
would be important to identify this family's strengths and to recognize their resilience in response to many stressors. Building open communication styles between family members and developing effective conflict-resolution strategies would hopefully enable Ryan's family to better cope with day-to-day problems. A more detailed description of some of the cognitive behavioral interventions suggested here can be found in Deblinger and Heflin's (1996) recent book on the treatment of sexually abused children and their nonoffending parents.
Adjunctive Interventions Given that Ryan has a major depressive disorder, it would be important to consider pharmacologic interventions if he does not respond to treatment. In this regard, if there is not significant improvement on depressive symptomatology or if suicidal ideation becomes more pervasive, I would recommend a psychiatric evaluation to assess whether a trial of antidepressant medication would be appropriate. Prognosis I believe that the prognosis for Ryan is good. Research has demonstrated the efficacy of CBT interventions with child sexual abuse victims. The treatment plan presented here incorporates both the CBT model and key elements from the humanistic approach. In particular, the development of a trusting therapeutic relationship will hopefully help Ryan to overcome the reduced interpersonal trust that he and many sexual abuse victims experience, which will likely enhance his responsiveness to the therapy experience. Given Ryan's presenting problems, I would anticipate that treatment could be completed in 15 to 20 sessions. I believe that the major obstacles to successful treatment for Ryan would be the existing conflict between Ryan and his stepfather and the negative perception that the parents generally have of Ryan. Accordingly, sessions with the parents and the family would be critical in addressing these issues in order to achieve a positive outcome.
References Cohen,J. A., & Mannarino, A. P. (1996a). A treatment outcome study for sexually abused preschool children: Initial findings. Journal of the American Academy of Child and Adolescent Psychiatry, 35, 42-50. Cohen, J. A., & Mannarino, A. P. (1996b). Factors that mediate treatment outcome of sexually abused preschool children. Journal of the American Academy of Child and Adolescent Psychiatry, 35, 14021410. Cohen, J. A., & Mannarino, A. R (1998a). Interventions for sexually abused children: Initial treatment outcome findings. Child Maltreatment, 3, 17-26. Cohen, J. A., & Mannarino, A. E (1998b). Factors that mediate treatment outcome of sexually abused preschool children: Six and
Response: Family Systems and CBT twelve month follow-up.Journal of the American Academy of Child and AdolescentPsychiatry, 37, 44-51. Deblinger, E., Lippman, J., & Steer, R. (1996). Sexually abused children suffering posttramnatic stress symptolns: Initial treatment outcome findings. Child Maltreatment, 1, 310-321. Deblinger, E., & Herin, A. H. (1996). Treatingsexually abused children and their nonoffendingparents: A cognitive behavioral approach. Newbury Park, CA: Sage Publications. Friedrich, W. N., Grambsch, E, Damon, L., Hewitt, S. K., Koverola, C., Lang, R., Wolfe, V., & Broughton, D. (1992). The Child Sexual Behavior Inventory: Normative and clinical comparisons. PsychologicalAssessment, 4, 303-311. Mannarino, A. E, & Cohen, J. A. (1996). Family-related variables and psychologicalsymptom formation in sexually abused girls.Journal of Child Sexual Abuse, 5, 105-120. Address correspondence to Anthony Mannarino, Ph.D., Allegheny General Hospital, Department of Psychiatry, 4 Allegheny Center, Pittsburgh, PA 15212. Received: November1, 1999 Accepted: December3, 1999
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Presenting Problems YAN, a 12-year-old boy with a history of sexual abuse, presents with symptoms of both disruptive and affective/anxiety symptom clusters. With respect to the former, Ryan has been fighting with peers, arguing with teachers, and exhibiting truancy. Similarly, oppositional and disrespectful behavior toward adults has been observed at home. He has been acting out sexually by grabbing other children's genitals and exhibiting other overt sexualized behavior. With respect to the affective/anxiety (internalizing) disorder symptom cluster, Ryan is exhibiting difficulty with sleeping, depressed mood, sense of pessimistic future, suicidal ideation, irritability, hypervigilance, attention/concentration, intrusive recollections of abuse, avoidance of trauma-related stimuli (internal and external), distrust of others/interpersonal difficulties with peers and adults and academics.
DSM-IV
ResponsePaper Integration of Family and Cognitive Behavioral Therapy for Treating Sexually Abused Children J a n Faust N o v a Southeastern University This paper demonstrates the application and integration of family systems therapy and cognitive behavioral therapy for the treatment of symptomatic children with histories of sexual abuse. This is achieved via the case of Ryan, a 12-year-old boy who had been sexually abused by two family members and who was experiencing affective/ anxiety symptoms and acting-out behavior problems. While this paper provides a theoretical rationale and comprehensive treatment plan, additional details of specific treatment interventions, from both treatment modalities, are delineated. From the family systems perspective, an emphasis is placed upon the discussion of realignment of family structure and changing familial communication patterns (including messages about safety, protection, and validation of children's experiences). From the cognitive behavioral paradigm, exposure therapy and cognitive restructuring are accentuated. Finally, the importance of the integration of both modalities without violating the theoretical assumptions of either is highlighted. Cognitive and Behavioral Practice 7, 361-368, 2000 1077-7229/00/361-36851.00/0 Copyright © 2000 by Association for Advancement of Behavior Therapy. All rights of reproduction in any form reserved.
Diagnosis
Axis I 309.81: posttraumatic stress disorder 296.22: major depressive episode-chronic, moderate 313.81: oppositional defiant disorder Axis II V71.09: no diagnosis Axis III None Axis IV Problems with primary support group (child abuse, family dysfunction) Educational problems (academic, peer, teacher) Axis V GAF = 50 (current)
A s s e s s m e n t Plan The assessment profile presented for Ryan is comprehensive. However, it may be useful to include measures that focus directly on the family and parenting. The Family Environment Scale (Moos & Moos, 1984), while widely used in research, can be used clinically to highlight strengths and weaknesses of family interaction and functioning. Parents* and child should complete these independently. Further, the Five Minute Speech Sample *Throughout the text, "parents" refers to Ryan's biological mother and stepfather.