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two of t h e m could n o t live in the same house. W h e n asked to explain m o r e a b o u t her fears, she stated that she was worried a b o u t her h u s b a n d favoring Michael. She also feels that her h u s b a n d is n o t able to spend m u c h time with Ryan because of his work schedule; however, when they do s p e n d time together, they argue frequently.

Response Paper Integrating Cognitive Behavioral Therapy into a Psychodynamic Framework AmyL. Hoch-Espada andJulie Lippmann University of Medicine & Dentistry of NewJersey, School of Osteopathic Medicine

References Achenbach, T. M., & Edelbrock, C. (1983). Manualforthe ChildBehavior Checklist and Revised Child BehaviorProfile. Burlington, VT: Author. Beck, A. T., & Steer, R. A. (1987). BeckDepressionInventory (BDI) manual. San Antonio, TX: The PsychologicalCorporation. Briere,J. (1995). The Trauma Symptom Checklistfor Children (TSCC) manual Odessa, FL: PsychologicalAssessmentResources. Cohen, J. A., & Mannarino, A. R (1996). 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. E, & Rogal, S. (1999). Treatmentpractices in childhood posttraumatic stress disorder.. Manuscript submitted for publication. Faust,J. (2000). Integration of familyand cognitivebehavioral therapy for treating sexuallyabused children: The case of Ryan. Cognitive and BehavioralPractice, 7, 361-368. Hoch-Espada, A. L., & Lippmann, J. (2000). Response to the case of Ryan: Integrating cognitive-behavioraltherapy into a psychodynamic framework. Cognitiveand BehavioralPractice, 7, 350-356. Kendatl-Tackett,K. A.,Williams,L. M., & Finkelhor, D. (1993). Impact of sexual abuse on children: A review and synthesis of recent empirical studies. PsychologicalBulletin, 113(1), 164-180. Kovacs, M. (1992). Children'sDepressionInventory (CDI) manual. North Tonawanda, NY:Multi-HealthSystems. Mannarino, A. E, & Cohen,J. A. (2000). Response to the case of Ryan: Integrating cognitivebehavioral and humanistic approaches. Cognitive and BehavioralPractice, 7, 357-361. Mannarino, A. E, Cohen,J. A., & Berman, S. R. (1994). The Children's Attributions and Perceptions Scale: A new measure of sexual abuse-related factors. Journal of Clinical Child Psychology, 23, 204211. Spielberger, C. D., Edwards, C. D., Lushene, R. E., Montouri, J., & Platzek, D. (1973). The State-Trait Anxiety Inventory for Children (STA[C) manual. Palo Alto, CA: Consulting PsychologistsPress. Address correspondence to Esther Deblinger, Ph.D., University of Medicine and Dentistry of New Jersey, School of Osteopathic Medicine, 42 East Laurel Road, Suite 1100b, Stratford, NJ 08084. Received: November1, 1999 Accepted: December3, 1999

The following case response seeks to integrate psychodynamic theory, cognitive-behavioral, and other interventions to provide an inclusive and holistic approach to the treatment of a 12-year-old male victim of sexual abuse. The case is complex in that it involves an adolescent with significant symptoms secondary to sexual abuse, including depression, suicidal ideation, posttraumatic stress disord~ dissociation, and sexually reactive behaviors. A psychodynamic conceptualization of the case offers insight into the therapeutic relationship and transference and countertransference issues; cognitive-behavioral theory and interventions are presented to address dysfunctional thoughts and problematic behaviors. Additional approaches to treatment and assessment are mentioned as means of providing sexual-abuse-specific treatment within a psychodynamic framework. Adjunctive interventions with parents and school staff are also addressed.

HE EFFICACY of cognitive-behavioral interventions in the t r e a t m e n t of posttraumatic stress disorder (PTSD), depression, suicidality, sexual behavior problems, a n d posttraumatic symptoms secondary to sexual abuse has b e e n supported in both the clinical a n d empirical literature. It is possible, however, to i m p l e m e n t cognitive behavioral techniques within the context of a broader, psychodynamic framework, allowing for an inclusive, individualized, a n d m u l t i d i m e n s i o n a l conceptualization of trauma a n d sexual abuse cases. Unfortunately, some clinicians may retain a n archaic a n d stereotyped picture of the psychodynamic therapist as a silent, withholding analyst sitting b e h i n d a p a t i e n t who is lying on the proverbial couch. That orthodox, analytic approach has n o t b e e n shown to be effective or appropriate with sexually abused children; in fact, the lack of any feedback or structure might well make children feel more anxious a n d shameful. Rather, the psychodyn a m i c perspective advocated here is o n e in which a strong therapeutic alliance is developed a n d n u r t u r e d as the vehicle for change a n d the child's psychological func-

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Response: Psychodynamic Framework tioning is supported by a degree of structure appropriate to the child's needs. Neutral yet genuine interaction takes place, and play and expressive materials may be used to foster communication about hopes, dreams, fantasies, and feelings. Abuse-related concerns may be introduced and discussed in ways that flow from the child's particular productions. In view of the centrality of the therapeutic relationship, attention is paid to transference and countertransference issues as they arise over the course of treatment. A psychodynamic approach attends to the developmental context in which the trauma occurred, the family background, the development and quality of attachments, the child's and parents' ego structures and resources, defenses, and personality organization. Understanding these facets of the client facilitates a more holistic understanding of the case and complements specific interventions for symptom relief. The assessm e n t and treatment plan to be described addresses these facets of the case while also incorporating interventions designed to target dysfunctional thoughts and problematic behaviors.

Presenting Problems Ryan, a 12-year-old male, presented for therapy subsequent to repeated sexual abuse by multiple perpetrators. He presented with posttraumatic stress and depressive symptoms as well as sexually reactive behaviors.

Diagnostic Impressions Without the opportunity to interview Ryan and his parents, Axis I diagnoses of PTSD and dysthymia are considered provisional.

Further Assessment In keeping with a holistic, psychodynamic approach to treatment, the assessment process should gather information regarding all aspects of the child's life. Friedrich (1990) advocates an assessment process that is ecological in focus and directly linked to treatment. Ecological assessment requires an understanding of each system impacting on the client, including family, school, community, child protective services, and legal arenas. In Ryan's case, the family and school environments are most important to consider. In view of the conflictual relationship between Ryan and his stepfather, for example, it would be important to try to involve the stepfather in the pretreatment assessment phase in order to elicit his perspective on Ryan's problems. Allowing him to ventilate his concerns and frustrations and making clear that his observations and expertise about his family and Ryan are

valued might serve to overcome his resistance to participate. The parental relationship, and each parent's level of attachment and detachment from Ryan, may be better assessed through a joint interview. With the family's permission, it might be beneficial to obtain information directly from Ryan's school, particularly any Child Study team referrals or evaluations. If the Child Study team has not been involved, the severity of his reading problems might be explored in order to ascertain if such a referral, to assess for specific learning disability, might be warranted. In order to make a definitive PTSD diagnosis and assess for any additional traumatic events, the Kiddie Schedule for Affective Disorders and Schizophrenia for SchoolAge Children (KSADS; McCleer, Deblinger, Henry, & Orvaschel, 1992) PTSD interview could be administered to Ryan and his mother. In addition, since his score on the dissociation scale of the Trauma Symptom Checklist was elevated, additional clarification of his dissociative symptoms might be accomplished using the Child Dissociative Checklist (Putnam, Helmers, & Trickett, 1993), a parent report that specifically measures observed dissociative behavior. Additionally, Silberg's (1996) Dissociative Features Profile can be used with any two standard psychological tests--including the Rorschach and TAT--to clarify, record, and score dissociative features. Projective tests have become less popular in recent years due to limited reliability and validity and the length of time needed to administer and score such instruments. Despite these concerns, projective testing allows the clinician to gain an understanding of the individual client's underlying defense structure, coping skills, ego resources, thought processes, potential for acting out, and internal controls. Many cognitive behavioral therapists prefer to utilize self-report instruments with more stringent normative data, which lend themselves to preand posttreatment comparisons and ongoing symptom monitoring. Such self-report measures, however, are facevalid and may be influenced by a client's minimization or exaggeration of symptoms. Using a combination of projective and self-report measures would provide a more comprehensive profile of the client. In a case like Ryan's, for example, with concerns about suicidality and sexual acting-out behavior, information regarding his capacity for internal control of his impulses may well be relevant to treatment planning. Thus, although projective testing is clearly not an appropriate means for assessing sexual abuse (no individual tests are), it may be a useful adjunctive tool for assessing personality and overall psychological functioning. James (1989) recommends assessing nine traumagenic states of children, representing an expansion of the four described by Browne and Finkelhor (1985): selfblame, powerlessness, loss and betrayal, fragmentation of

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Case Conceptualization Ryan's symptom profile is consistent with the Axis I diagnosis of PTSD, including repetitive, abuse-related nightmares, intrusive thoughts, avoidance of thoughts and reminders of abuse, restricted affect, a sense of foreshortening, increased irritability, unexplained angry outbursts, hypervigilance, and physiological reactivity to abuse reminders. Ryan is also experiencing suicidal ideation and has not been willing to contract for safety. Furthermore, his engagement in sexually reactive behavior presents a danger of victimization to others around him. Thus, it would appear that the main issue to be addressed is safety. Ryan's dangerous behaviors may be understood as symbolic or literal reenactments of the initial sexual abuse. These behavioral reenactments serve the purpose of modulating uncomfortable feeling states in the absence of more adaptive self-soothing strategies. Ryan's behaviors may be viewed as attempts to gain mastery by reenactment, this time as the aggressor. Through his risky or dangerous behavior, Ryan tries to feel powerful and in control. It appears that he uses the suicidal ideation and sexual behaviors as strategies to relieve tension rather than confronting and working through his underlying turmoil. It would be expected that a core dynamic for Ryan would be a struggle around trust. Ryan's capacity to trust is likely to have been damaged by repeated sexual abuse experiences that occurred in the context of ostensibly trusting, dependent relationships. Ryan was abused, beginning at a fairly young age and recurring for an extended period of time, by his father, who separated from the family; he was also abused by a cousin. The experiences of abandonment and betrayal inherent in his trauma are integrated into Ryan's expectations of himself and others in the world. Given the primacy, from a psychodynamic perspective, of a trusting therapeutic relationship to facilitate change, the development and maintenance of such a trusting relationship with Ryan is likely to be an ongoing theme in his sessions. Ryan has endured many losses in the p a s t - including his parents' divorce, the loss of trust in his father and babysitter--and now, perhaps, faces rejection by his stepfather. These interpersonal events all impact on Ryan's ability to relate to his therapist. In addition, the power, control, and sexual issues to

which Ryan was subjected in his relationship to abusive authority figures are likely to surface in his relationship to his therapist. During the sexual abuse, Ryan was helpless. He felt powerless and unprotected by those around him. The memory of that experience pervades all subsequent relationships. Consequently, Ryan feels a need for control in all aspects of his life. With control comes power, which Ryan uses to defend against further feelings of helplessness. Ryan also has a disrupted sense of selfcontrol. It appears that dissociation may be one way to control his thoughts and feelings, keeping these isolated and outside of his conscious awareness. He attempts to control his affect by not allowing himself to experience certain painful thoughts or memories. Inevitably, Ryan struggles with interpersonal connection and self-intimacy. He has difficulty treating himself in a caring manner and often disrupts connections with others with his sexually reactive or oppositional behavior.

Transference/Countertransference Psychodynamic treatment of the sequelae of trauma emphasizes consideration of transference and countertransference issues. Because the psychotherapeutic process is often terrifying for survivor clients and the potential for early negative transference is high, treatment failures, impasses, premature termination, negative therapeutic reactions, and early flight from treatment are great risks in these therapies. Careful, ongoing examination of transference and countertransference reactions and tracking of the interpersonal aspects of the therapy are essential to creating and preserving a protected space or facilitating environment for the transformative work of the therapy. (Pearlman & Saakvitne, 1995, p. 58) Likewise, H e r m a n (1992) discusses traumatic transference reactions: Patients who suffer from a traumatic syndrome form a characteristic type of transference in the therapy relationships. Their emotional responses to any person in a position of authority have been deformed by the experience of t e r r o r . . , and helplessness. For this reason, traumatic transference reactions have an intense life-or-death quality unparalleled in ordinary therapy. (p. 136) Themes of power, autonomy, and control may emerge. In this case, in view of his history of oppositional behavior, one might anticipate that Ryan may try to control the therapist and the boundaries of treatment in order to quiet his own unease about the therapeutic relationship. He may vie for control in the sessions and cast the thera-

Response: Psychodynamic Framework pist in the role of perpetrator a n d / o r of inadequately protective parent. For example, clients may experience any probing or questioning by the therapist as intrusive and aggressive, viewing these as attempts to overpower them and violate the personal space of their thoughts and feelings in a way that reminds them o f the abuse. In response to that perception, clients may change the topic, ignore questions, or turn the tables on their therapists by asking particular questions of them. In this way, the client becomes the "aggressor" and can preserve a sense of control. A n o t h e r transference theme related to control and trust may emerge a r o u n d issues of safety and comfort. Adolescent clients who report suicidal ideation and gestures are at risk for making suicide attempts. Therefore, they need to be informed directly of the limits of confidentiality regarding these potentially dangerous behaviors; this may be conveyed explicitly and concretely in a safety contract. Yet, despite presentation of these clear guidelines at the onset of therapy, teen clients may request that the therapist not tell their parents about suicidal gestures. A client might tell the therapist about a vulnerable m o m e n t in which he or she contemplated or, more seriously, acted on a t h o u g h t of self-harm and plead that the parents not be told. Even after the therapist reiterates and explains her position, and offers the client the opportunity to inform his parents together, the client may respond with feelings of anger and betrayal. In essence, the client unconsciously reenacts a scenario of abuse in which the therapist has, symbolically, betrayed the client, and now faces the brunt of the client's rage and scorn. No wonder they cannot trust anyone; people take advantage of them at their weakest moments. The client then views the therapist as someone to fear. These and other transference examples may trigger a host of intense countertransference reactions in the therapist, which must be acknowledged and processed, with or without the client, in order to transform the therapeutic relationship from one of reenactment to one of healing. While strict cognitive-behavioral therapists see themselves as teachers and educators, it is helpful for therapists to respect the views of the world and of others that clients bring into their therapy and project onto their therapists, as well as to recognize the powerful reactions that may be elicited in themselves. Countertransference reactions can range from anger to protectiveness. In the previous examples, the therapist might respond to the client with anger and resentment at his lack of gratitude. Therapists often view themselves as helpers; when clients repeatedly reject their efforts to help and move the clients forward in treatment, therapists may begin to feel resentful or insecure about their own skills. These emotional reactions, when unrecognized, can trigger boundary violations a n d / o r responses based

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on the therapists', rather than the clients', needs. For example, if Ryan were to report frequent episodes of suicidal ideation or even gestures, the therapist might begin to feel disappointed and frustrated with his lack of progress. One possible reaction from the therapist might be anger at Ryan's "manipulative" and "attention-seeking" behavior. Instead of remaining neutral and planning a consistent therapeutic reaction to these repeated reports, the therapist might begin to minimize such statements and gestures a n d / o r to react with frustration. Mternatively, the therapist might begin to feel anxious, insecure, and doubtful about her ability to treat Ryan successfully. In response to such feelings, a therapist might allow the client to call her at h o m e at all hours in an emergency, rather than to foster his own coping mechanisms. Such countertransference reactions serve to alleviate the therapist's immediate feelings of frustration and insecurity, but at the expense of the client's best outcome. A n o t h e r c o m m o n countertransference response in abuse cases is one of trying to rescue the client. Bearing witness to the details of Ryan's repeated abuse experiences might trigger the therapist's sadness and anger, which may be transformed into feelings of responsibility for rescuing him from his pain. To compensate, she might try to spare him (and herself) the discomfort of talking about difficult abuse issues, and thereby inadvertently encourage further avoidance. She might give him extra time in session, answer personal questions, a n d / o r give him gifts. These countertransference reactions may be especially intense when working with multiply victimized, disadvantaged children who have unstable families and fewer resources in general. Yet, these reactions may confuse and frighten clients and ultimately detract from the therapeutic process. Finally, in Ryan's case, the therapist might react strongly to his exhibiting sexualized behaviors both inside and outside of the office. Therapists may react with disgust, anger, fear, or titillation to such overt sexualized behavior--reactions that can serve to reinforce the behavior a n d / o r distance the therapist from the client. Thus, acknowledgement and respect for transference and countertransference issues are essential when working with any client, especially those with significant victimization histories. These reenactments and reactions can then be utilized in treatment to help transform abusive relational patterns into healthier ones.

Therapy Plan Describing the process of healing for adult survivors of trauma, H e r m a n (1992) states, "The core experiences of psychological trauma are disempowerment and disconnection from others. Recovery, therefore, is based u p o n the e m p o w e r m e n t of the survivor and the creation

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Hoch-Espada & Lippmann of new connections." Trauma work is done within three general phases of recovery (Courtois, 1999): 1. Early phase--includes alliance building, safety, and stabilization. This stage is measured by mastery of skills and safety, not time. Restoring control to the client is the goal. 2. Middle phase--includes trauma work, gradual exposure, mourning, and resolution. 3. Late phase--includes self- and relational development, reconnection with ordinary life, and creating a future. Within these general phases, James (1989) outlines a multidimensional approach to treating traumatized children. The central goal is to help the child accept his or her experience. Specifically, there are four major categories of the treatment process that may be interspersed throughout the stages of treatment: • Communication: learning how to identify and express feelings; • Sorting out: exploration and understanding of the trauma; • Education: understanding of the specific components of the traumatic experience; and • Perspective: acceptance of the trauma within the context and narrative of one's life. The therapeutic process is not a linear one with discrete, contained phases. Rather, the treatment process ebbs and flows, moving within and among phases as the trauma's meaning is revisited and reworked in each new phase. Specifically, treatment for Ryan would offer him help and support in developing trust in others. Within the context of the developing therapeutic relationship, Ryan could explore the reasons and responsibility for the abuse, develop alternative coping skills, gradually process his traumatic experiences, mourn the losses he endured, and plan his future so that he neither victimizes others nor is revictimized himself. Once the pretreatment assessment is completed and therapy begins in earnest, a consistent, supportive therapeutic stance will facilitate the development of rapport, safety, expression of feelings, and sense of mastery of himself and his environment. In the second session, Ryan discloses limited information about his abuse, on which he refuses to elaborate. Although the therapist may feel discouraged that he will not provide more details, it is important to provide acceptance, support, and praise for his ability to share this information. Ryan will be very attuned to the therapist's response to his disclosure, so a calm, neutral response, with reflective and supportive statements, would be appropriate. It might be helpful, in addition, to provide some general information about child

sexual abuse. During this early interchange, Ryan is receiving several important healing messages from the therapist's acceptance: If the therapist knows what happens and still likes me, maybe I ' m not so bad . . . . I ' m likeable; I ' m worthy of someone's respect; I am not alone. Over time, these messages will be reiterated, integrated, and internalized. However, trust, identity, and intimacy issues are embedded within these messages and will need revisiting and reworking throughout the phases of therapy. A safety contract should be developed in collaboration with Ryan to include suicidal ideation, self-destructive behavior, and sexually reactive behaviol: Psychodynamic and cognitive-behavioral techniques could then be used to gradually address victimization and perpetration issues. Using stories and metaphors to initially address Ryan's issues may prove more effective than immediately focusing on his behavioral incidents of acting out. As Ryan is able to tolerate these sessions, therapy can become more directive but still dual-focused and should include exploration, psychoeducation, gradual exposure, social problem solving, social skills training, and selfinstruction. Before confronting any traumatic material, enhancement of Ryan's emotional expression skills will improve his ability to identify and verbalize feelings during the therapy process. This is a first step in teaching Ryan to use words rather than actions to modulate his feeling states. Furthermore, Ryan's improved communication skills will later enhance his ability to process his traumatic experiences. Once Ryan is able to better express himself, he can begin to explore, at a comfortable pace, the traumas in his life. It is important that a strong therapeutic alliance be developed between the therapist and client for this process to be effective. Because safety and control issues are of significance with trauma victims, Winnicott's (1960) concept of a safe, "holding" environment should be established. Again, the relationship between therapist and client will provide stability and comfort in session. As Ryan identifies with his therapist and internalizes the therapist's empowering messages, Ryan will carry his therapist with him outside of session and into the world. For Ryan to work through his own experiences of victimization, talking, drawing, or writing these experiences can help him process his thoughts and feelings. Gradual exposure and cognitive processing allow Ryan to confront his memories and integrate the thoughts and feelings he had during those episodes. For Ryan, thoughts, sensations, feelings, and behaviors may be disconnected, dissociated from each other. This compartmentalization allows Ryan to vent overwhelming feelings like anger without having to think about the memory that is making him angry. Integration of these disparate pieces is essen-

Response: Psychodynamic Framework tial in order to process the abuse fully. However, as Van der Kolk (Van der Kolk, McFarlane, & Weisaeth, 1996) and others point out, traumatic memories are often encoded nonverbally in the body, and therefore may be inaccessible to traditional talk therapies. Nonverbal techniques may be used to help clients process the nonverbal aspects of their abuse. In addition to Eye Movement Desensitization and Reprocessing (EMDR; Shapiro, 1 9 9 5 ) which should only be utilized by therapists with specific and extensive training in the modality--other nonverbal methods may be used adjunctively, both within and outside the session, to help access and actively rework body memories of the abuse and thereby process the trauma. Such methods include drawing and other expressive arts, self-defense classes, and meditation. Ryan might be encouraged to engage in nonaggressive sports, draw in a journal, or take yoga or karate to facilitate strength, anger management, and his feelings of empowerment and control. He could then talk about these experiences in his therapy in order to integrate them. Throughout treatment it may be beneficial to provide both Ryan and his parents with information on child sexual abuse. As part of the gradual exposure process, talking about general information on sexual abuse may be a first step in confronting thoughts and feelings about his own victimization. This information may spark further questions and discussion about his own personal experiences of sexual abuse. Ryan clearly needs to augment his repertoire of coping skills to include self-esteem and emotional expression development, anger management, social skills training, social problem solving, and self-instruction. These skills can then be utilized in the course of the trauma work to reduce the risk of retraumatization a n d / o r relapse of sexually reactive behavior. Age-appropriate sex education should be addressed so that Ryan can receive accurate information about sex/ sexuality and explore the differences between sexual abuse and a healthy physical and emotional relationship. Time should also be taken to address abuse response skills via discussion and role-plays. Ryan's sexually reactive and offending behavior will need to be addressed directly throughout the treatment process. Specific issues involve denial, taking responsibility for his actions, making amends, scapegoating, and ritualization/compulsivity of the behavior (Cunningham & MacFarlane, 1996). Extrapolating downward from therapeutic strategies used with adult and juvenile offenders, work with sexually reactive children helps them to unders t a n d - - o n an age-appropriate level--and identify their own "abuse cycles" and develop individualized relapseprevention plans. It is important that Ryan confront his behavior and the feelings surrounding it. Thus Ryan needs to learn to recognize the feelings that appear to

trigger his sexualized behaviors and to find alternative means to cope with those feelings so that he does not resort to acting them out with other children. As therapy draws to a close, loss issues will need to be confronted and plans for the future developed. At termination, Ryan should be able to identify and express feelings, identify triggers for sexually reactive behaviors, utilize coping skills to manage these behaviors as well as any residual PTSD symptoms, and engage in socially appropriate behavior within a support system he has developed.

Adjunctive Interventions It is recommended that Ryan's parents participate in adjunctive therapy on behalf of their son. As with Ryan, the therapist's relationship with Ryan's parents will have a significant impact on their own healing process, which in turn will benefit Ryan. It is unclear if Ryan's stepfather's resistance to participation in treatment is because he is detaching from Ryan or if Ryan's problems are creating conflicts between Ryan's parents. Before the therapist can do any concrete work with either parent on the sexual abuse, these issues need to be explored. If Ryan's stepfather would be willing to meet with the therapist for a limited time, the therapist could explore the stepfather's feelings. Perhaps he feels physically and emotionally awkward around Ryan because of the sexual abuse. He may wonder if he should touch Ryan or talk with him about the abuse. He may wonder how Ryan views him as a father figure in comparison to his abusive biological father. It may be that Ryan's stepfather is concerned about Ryan's sexuality, as many parents are after a child has been sexually abused, and does not know how to address those feelings. There are many possibilities for engaging Ryan's stepfather in treatment. Supportive strategies are helpful during this exploratory phase. On the other hand, if it is the case that Ryan's parents are having marital difficulties because of Ryan's problems, they can be encouraged to seek marital counseling in addition to the specific work around the sexual abuse. Research has shown that nonoffending parent support following a child's disclosure about sexual abuse is the most important factor in determining the child's psychological adjustment (Adams-Tucker, 1981; Conte & Schuerman, 1987; Everson, Hunter, Runyon, Edelson, & Coulter, 1989.) Parents often have difficulty coping with the knowledge that their child has been sexually abused and the management of any resulting behavior problems. In Ryan's case, providing the parents with information about sexual abuse and sexually reactive behavior may help them put the issues into perspective and combat some of Ryan's mother's guilt and responsibility for the abuse. It is important that they, like Ryan, learn to utilize various coping skills to help them manage their

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feelings a b o u t the abuse, i n c l u d i n g Ryan's m o t h e r ' s depression a n d fear that Ryan will be affected by the abuse for the rest o f his life. Ryan's parents would also benefit from a g r a d u a l e x p o s u r e process to h e l p t h e m c o n f r o n t a n d cope with discussions a b o u t Ryan's sexual abuse with or without him. I n c l u d e d in this c o m p o n e n t o f t h e r a p y would be discussion a b o u t a g e - a p p r o p r i a t e sex education, with the goal that they will eventually, if n o t already, be taking on a t h e r a p e u t i c role with their son. P a r e n t training a n d behavior m a n a g e m e n t will be essential in this case in o r d e r to c o m b a t Ryan's sexually reactive a n d o p p o s i t i o n a l behaviors. After a disclosure o f sexual abuse, parents often focus on the p r o b l e m s a n d negative behaviors their child is exhibiting. Having parents b e g i n to notice the strengths a n d positive behaviors their child is displaying works to shift the focus o f attention f r o m o n e o f frustration a n d d e s p a i r to h o p e a n d relief. Parents can be c o a c h e d to choose behaviors they want to increase a n d a t t e n d to t h e m more, thereby reinforcing their presence. Ryan's parents can be c o a c h e d to reinforce behaviors such as following rules, r e s p o n d i n g to requests, respectful talk, a n d okay touch experiences. In addition, Ryan's parents can be c o a c h e d to utilize b e h a v i o r - m a n a g e m e n t techniques in response to notokay t o u c h i n g a n d opposifional behavior. Collaboration with Ryan's t e a c h e r to develop a behavior m a n a g e m e n t plan at school is also r e c o m m e n d e d . In this way, he will receive a consistent response to his sexualized a n d o p p o s i t i o n a l behaviors b o t h at h o m e a n d at school.

Expected O u t c o m e With the s u p p o r t o f his parents, Ryan has the o p p o r t u nity to c o n f r o n t a n d work t h r o u g h victimization issues in therapy a n d learn to m a n a g e his sexualized a n d oppositional behaviors. While it is difficult to p r e d i c t o u t c o m e in an individual case, PTSD symptoms like Ryan's have b e e n shown to be responsive to an individual cognitivebehavioral a p p r o a c h involving gradual exposure, cognitive coping, a n d processing. Depression a n d behavioral p r o b l e m s are a m e n a b l e particularly w h e n the cognitivebehavioral a p p r o a c h involves p a r e n t p a r t i c i p a t i o n (Deblinger, L i p p m a n n , & Steer, 1996). A l t h o u g h Ryan has h a d several losses a n d betrayals in his life, he has had, t h r o u g h o u t , an o n g o i n g a n d supportive relationship with his mother, an i m p o r t a n t a n d positive prognostic sign. Many a d d i t i o n a l factors will i m p a c t the o u t c o m e o f therapy, i n c l u d i n g Ryan's levels o f depression, impulsivity, a n d motivation, a n d his p a r e n t s ' stability, support, a n d consistency in b r i n g i n g him to his sessions. Ideally, a d e v e l o p m e n t a l l y s e q u e n c e d t r e a t m e n t

(James, 1989) f o r m a t is r e c o m m e n d e d , wherein the therapist maintains an o n g o i n g professional relationship with the client a n d his family, who may r e t u r n for a d d i t i o n a l services as n e e d e d . In this way, as the child a p p r o a c h e s various d e v e l o p m e n t a l periods, which may trigger new issues related to the sexual abuse, the therapist is available to treat these a g e - a p p r o p r i a t e concerns as they arise. This a p p r o a c h can work even within a m a n a g e d health-care system; r a t h e r than r e q u i r i n g long-term therapy, this developmentally s e q u e n c e d t r e a t m e n t allows t r a u m a work to p r o c e e d in chunks a n d gains to consolidate over time.

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