Harms Of Child Sexual Abuse And Therapy
Sexual abuse and sexual violence is seen to occur in all ages, socioeconomic classes, and nearly in all countries, all with varying magnitude (Singh, et. al. 2014). Child sexual abuse (CSA) specifically, is not a novel concept to society. It has been a universal problem that is still practiced well into modern society. CSA has been shown to entail grave life-altering consequences that affects more than just the victims. Victims are show to have signs of PTSD, depression, suicide, poor academic performance, sexual promiscuity, and victim-perpetrator cycle (Paolucci, et. al, 1999). In fact, it had been one of the longest social cancers that has been constantly shrouded behind the public eye. History illustrates a long and gruesome portrait of CSA. One striking example as written by Mintz (2012), many historians believe that it was commonplace in elite households in the fifteenth and sixteenth century Europe to have used children as sexual playthings.
This intergenerational problem paints a sordid tapestry of an endless cycle of abuse of power and the constant way to normalize very compromising situations. It is in these circumstances that this social cancer has been one of the least talked up until recent years. It makes the public squirm, but it does not invoke the expected outcry or action because most of it had once been considered as a the quiet shameful norm. In the advent of the #metoo movement, women and men alike have been reluctant to come forward and share their stories on their experiences of CSA, mostly because of the labels and the stigma that the victims would be fighting against. But in recent years, CSA has once again been scrutinized because of all of the surfaced allegations of prominent people in the church, in politics, and in several places in the media.
However even though the issue is thriving in the limelight, much of the practice is still very much alive, as its evidences are obvious even in the most overt places around the world. A striking example can be found in Bangladesh. Despite it being an Islamic country, it houses a town named Dalautdia, where approximately 1,500 women work as prostitutes - some of which are as young as 10 years old (Al Jazeera, 2017).
In some countries in Southeast Asia, the commercial sex trade is one of its biggest industries. And this industry also takes advantage of children, particularly in sexual exploitation. In recent years, child sexual exploitation (CSE) have been escalating in the Philippines (Stairway Foundation Inc. , 2012). According to Yacat, et. al (2015), CSA accounted for 35. 8% of the number of cases held by the Department of Social Welfare and Development back in 2006 and it was emphasized that the data did not include the data recorded by non-governmental organizations (NGO’s) and other different private institutions across the archipelago. Most of the time, they are marketed by other people, but in some cases the children are the ones who market themselves in exchange for favors such as a place to sleep, or protection. In 2005, there was a report made by the Consortium Against Trafficking of Children and Women for Sexual Exploitation that disclosed that the country has about 60,000 to 100,000 prostituted children, and is a transit destination country for internationally trafficked persons (Stairway Foundation Inc., 2012).
Child Sexual Abuse in a Nutshell When WHO established their Consultation on Child Abuse Prevention in 1999, they defined CSA with three prongs: a) that the child is unable to comprehend the situation that they are in; b) that the child is unable to give informed consent with the action about to or being practiced; and c) an act that violates the laws or social taboos of society (Singh, et. al. 2014). Multiple countries have already tried their best to address the issue with the laws that they establish. And according to the United Nations Convention on the Rights of the Child (CRC), it clearly states that CSA is a violation of a child’s human right (Stairway Foundation Inc. , 2012). There are broader aspects that would influence the decision making of the perpetrator - such as culture, societal norms, and laws. But stripped down, CSA plays more to the role of the imbalance of power in the relationship between the aggressor and the victim. In fact, the abuse of the relationship between the perpetrator and the victim is what is at the core of the abuse (Stairway Foundation Inc. , 2012). It also takes advantage of the vulnerabilities of the victims. In most situations children lack the authority and are often told what to do. They have limited resource for refusal, complaint, or negotiation (Quadara et. al, 2017).
Cognitive Behavioral Therapy as a Form of Treatment
At its core, Cognitive Behavioral Therapy focuses on making sense of what happened to the victim and how it affects them. It is a journey into personal meaning making at the edge of mind and objective experience (University of Manchester Library, 2008). Slade and Warne (2016) emphasized that there are many unfortunate types of abuse a child undergoes, hence the development of multiple treatments in hopes to address them. The most common that is found out there is CBT and Play Therapy (Kaduson, 2011 in Slade and Warne, 2016). How Slade and Warne (2016) detailed CBT in their study can be pertinent to defining the inner workings of Trauma Focused CBT (TF-CBT).
The most notable deviation that TF-CBT takes is how it is especially sensitive to the psychological problems that would arise from trauma. It injects “trauma work” in its formula, where it is defined as “the need to address feelings of shame, emotional distress and depression” (Neubauer, et. al. , 2007 as cited in Holtzhausen, et. al, 2016). This type of psychotherapeutic approach was specifically developed for children aged 3 to 17 and for their parents or primary caregivers (Holtzhausen, et. al, 2016). TF-CBT was developed to address the multiple negative consequences that stemmed from traumatic life events (Cohen, Mannarino & Deblinger, 2006 as referenced in Holtzhausen, et. al, 2016).
TF-CBT is a hybrid model that integrates different psychotherapeutic approaches. It combines elements of cognitive therapy, behavioral therapy, family therapy, affective and humanistic treatments into an approach design to tackle the unique needs of each client with problems that root in traumatic experiences (Smith, Yule & Perrin, 2007 in Murray et. al, 2016; Child Welfare Information Gateway, 2012). Typically, the TF-CBT consists of 12-16 sessions divided into three phases. Slade and Warne (2016) characterized the phases as such: The first phase involves the client and the parent undergoing gradual exposure to traumatic content, slowly focusing on the client’s experiences in reaction to the general traumatic content that they are exposed to. The second phase has the client detailing the trauma in what is termed as a “trauma narrative”. It mainly functions as a means of therapeutic exposure and helps to facilitate cognitive and emotional processing.
Many consider the “trauma narrative” being very helpful to victims of all forms of abuse (Classen et al, 2011; Misurell et. al., 2011 in Slade and Warne, 2016). The third phase would now focus on the development of skills to ensure the safety of the client and other skills for the client’s future growth. The main goal of the session is to empower these victims and their parents with a knowledge-based essential for therapy. Another goal is to provide the necessary skill set that would foster good coping strategies and regulation skills to help inhibit the lasting effects of the trauma. In short, TF-CBT provides psychological assistance as well as education to to the clients and it assists in developing coping mechanisms when they are confronted with any abuse-related memories and feelings (Holtzhausen, et. al, 2016). TF-CBT has been seen to be implemented in various areas and environments such as urban areas, rural areas, in clinics, schools, homes and residential treatment facilities. It has also demonstrated its effectiveness with children of different cultural backgrounds (Weiner, Schneider, & Lyons, 2009 in Child Welfare Information Gateway, 2012).
In the investigative literature of Holtzhausen, et. al (2016)’s study, they have discovered that TF-CBT have impressive empirical support (Black, Woodworth & Tremblay, 2012; Holstead & Dalton, 2013; Vieth et. al. , 2012; MacDonald et. al. , 2012; Sigel et. al. , 2013; Murray et. al. , 2016) when it comes to treating clients who are victims of CSA. It has been seen to treat PTSD-related symptoms of clients. There were also evidences that pointed in the reduction of symptoms related to comorbid disorders, and that the positive effects of this type of treatment are long lasting according to Sheeringa et. al, (2011).
CBT in itself is a powerful tool for the betterment of the mental space of a client. It seeks to help with how the client manages their thoughts, their beliefs and their translating actions. There is no dismissing its efficacy. Multiple researchers have confirmed its efficacy in terms of the client’s behavior, coupled with the parenting style of their parents or their primary caregivers (Deblinger, et. al. , 2010). One of the main things that would boost the efficacy of this psychotherapeutic approach is the “trauma narrative” that would allow the client to fully express their trauma in gradual, bite-sized instances that would also allow the therapist to guide them into understanding what had happened with them and what other negative thoughts and emotions attached to the stimuli.
It has also been noted that while TF-CBT is seen to improve the clients in almost all aspects, it does not impact the externalizing outcomes for them. Slade and Warne (2016) had noted in their study that it was in PT that they had found more positive outcomes for their clients than in CBT. This is also backed up by Miller, Rathus, & Linehan (2007), as stated by the Child Welfare Information Gateway (2012) where they cautioned that TF-CBT is not going to be as effective for suicidal clients, or clients that exhibit parasuicidal behavior. They have instead prescribed Dialectical Behavioral Therapy (DBT), another specific kind of CBT.
One critique that is often emphasized is the lack of cultural variables and the lack of recognition of the distinctive clinical needs of underprivileged groups and populations that do not herald from the West. (Brown, 2006; Levant & Silverstein, 2006; Olkin & Taliaferro, 2006; Sue & Zane, 2006 in Holtzhausen, et. al, 2016). And this is reflective to most of the literature written for the efficacy of TF-CBT. This method is hardly studied with other cultural groups and are mostly popular among Western societies. There had been little literature regarding the inclusion of other cultures and its efficacy.
Taking into the context of culturality, the Philippines’ culture is a conglomerate: it has strong Western influences, given our history, and at the same time it houses multiple unique cultures and subcultures that in its social underbelly. That in itself poses a problem towards trying to fit a psychotherapeutic approach, let alone an approach as rigorous as TF-CBT. In administering TF-CBT to victims of CSA in the Philippines, there are would-be problems that a practitioner may encounter. The language barrier may be one thing. Since the profile of the children who are usually victims of CSA are that of the marginalized, some might not have received a proper education, and would have difficulty understanding certain parts of the therapy process. This factor could also apply to the primary caregivers of the victim.
The issue of translation is also a possible roadblock for the administration of this psychotherapeutic strategy. Since the Philippines is home to several dialects, it would be both very physically and mentally demanding to translate and interpret the manuals and topics provided for each session, unless the practitioner themselves are well-versed in the language that their client is speaking.
Conclusion
There had always been the concern that there is very few literature regarding the efficacy of any type of psychotherapeutic approaches in the healing process of Filipino children who are victims of CSA. Studies conducted noted that mostly the psychotherapeutic approach that is being done is largely eclectic, and had been prone to experimentation and exploration. The theory is largely lost, and if ever a theory-based approach will be practiced, the approach will most likely come from the west (Dela Cruz, et. al. , 2000 in Yacat, et. al, 2015). Yacat (2015) also emphasized that most of the approaches that are being practiced here in the Philippines are largely for individual sessions, and very few studies are conducted in favor of group sessions.
In terms of the effectiveness of TF-CBT to Filipino victims of CSA, there had not been empirical evidence to draw conclusion from. Since most of the literature contain practitioners using eclectic forms of psychotherapeutic strategies, it is wise to further research the effectiveness of CBT and TF-CBT in a study that would focus on the cultural aspect of the victims. But for now, every practitioner is always cautioned to ‘do no harm’ would just continue to practice in good faith.
