Group Therapy Interventions for Sexual Abuse Survivors

1. Group Therapy Interventions for Sexual Abuse Survivors Maggie Robinson, M.S, LPC-S, NCC, Registered Play Therapist Kathy DuMond, M.Ed., LPC, NCC, Registered Play Therapist

2. Who are we and what we do?

3. Goals of Treatment • To provide child with a positive and meaningful experience • To improve daily functioning • To correct cognitive distortions related to the abuse • To acknowledge and reduce trauma • To prevent further abuse/victimization

4. Group Therapy • Therapy in the presence of a therapist in which several patients discuss and share their personal problems. (Merriam-Webster Dictionary) • Group therapy approximately 6-10 individuals meet face-to-face with a trained group therapist.

5. Group Therapy Objectives • Process group • Build healthy relationships and learn appropriate social skills. • Help group identify and express feelings and thoughts related to abuse. • Triggers • Self image • Self esteem • Develop and implement appropriate coping skills. • Decrease level of reaction to triggers. • Restructure triggers. • Implement steps to prevent future abuse. • Dynamics of sexual abuse • Boundary setting

6. Group Therapy Objectives • Support group • Build healthy relationships and appropriate social skills. • Decrease sense of isolation and build sense of belonging. • Increase self esteem. • Support rather than confront. • Make connections between feelings and actions. • Learn warning signs to prevent future abuse. • Learn dynamics of sexual abuse. • Empower to support healing within the family system.

7. Benefits of Group Therapy • Develop new ways of relating to others. • See they are not alone and others have experienced traumatic events. • Support and help. • Gain hope. • Develop trust within group. • Learn ways to communicate and share feelings appropriately.

8. Benefits of Group Therapy • Research • Conte, Briere and Sexton (1989)- more than 700 variables thought to have impact on treatment of sexual abuse • Indication that family/other major adult support and peer support significantly reduce the long term effects.

9. Disadvantages of Group Therapy • Breach of confidentiality. • Feeling uncomfortable. • Harmful conversation and feedback from members. • Discussion off topic. • Inappropriate members.

10. Trauma • A disordered psychic or behavioral state resulting from severe mental or emotional stress or physical injury; an emotional upset • Taken from Merriam-Webster Dictionary • Traumatic events differ from ordinary stressful events. They are sudden, unpredictable, and overwhelming, leaving a child no opportunity to prepare for them. Trauma refers to events involving injury, death, or the threat of one’s own or another’s safety. Aside from physical injury, trauma may also cause emotional injury to a child.

11. Post-Traumatic Stress Disorder (PTSD) • What Causes PTSD • A person develops PTSD in response to an extreme trauma. The experience causes that person to feel intense fear, horror or a sense of helplessness. • 3 Symptom Clusters of PTSD • Re-living the event via nightmares or intrusive images, also have extreme emotional or physical reactions – shaking, chills, heart palpitations, or panic • In younger children can be seen in repetitive play involving thematic recreations of the traumatic event • Avoiding reminders of the event • Being on guard or hyper-aroused • Irritability, sudden anger, sleep difficulties, lack of concentration, overly alert or easily startled

12. Treatment Issues • Guilt and shame • Betrayal/trust • Stigmatization • Depression • Poor self esteem • Anger • Fear/anxiety • Powerlessness • Traumatic sexualization • Prevention • Family Issues

13. Treatment Philosophy • Interventions should be abuse focused • Need to go at a pace that does not re-traumatize the child • Combine directive with non-directive approaches • Psycho-education important • Essential to involve the caregiver • Therapy is open-ended

14. Treatment Stages • Feeling identification and expression • Symptom reduction • Processing trauma • Psycho-education • Prevention/protection • Termination

15. Feeling Identification and Expression • Feeling identification can help child establish trust and rapport with therapist and group • Important to learn healthy feeling expression • Helpful to normalize feelings • Child needs to understand that feelings, even negative ones, are okay • Essential to express feelings about abuse/abuser

16. Feeling Identification and ExpressionActivities • Feelings Bingo • Feelings Checkers • Feelings in My Body • Bag of Rocks • Talking, Feeling, Doing Game

17. Common Symptoms • Crying • Sadness • Fearfulness • Nightmares • Anger & Mood Changes • Aggressiveness/fighting • Withdrawal from others • Increased anxiety • Changes in school performance • Sexually inappropriate behaviors

18. Common Symptoms cont’d • Clinging to caregiver • Changes in appetite/eating patterns • Regression • Temper tantrums • Daydreaming/difficulty concentrating • Somatic complaints • Poor self-esteem • Running away • Substance abuse • Flashbacks

19. Symptom Reduction Activities • Self Esteem • ABC I Like Me • I’m Gonna Like Me • Flower Pot Activity • Name Activity • I am so much more • Self Care • Self Care Calendar • Muscle Relaxation • Meditation

20. Symptom Reduction Activities cont’d • Support • My Helpers • People in My World • Support People • Triggers • Things that Remind me of the Sexual Abuse • Nightmares • Dream Pillows • Dream Catchers

21. Processing the Trauma • To teach child to manage distressing thoughts, feelings, and behaviors regarding the abuse • To allow child to process the traumatic event(s) and give it realistic meaning and store as a tolerable memory • To ascertain the meaning of the abuse and correct cognitive distortions

22. Processing the Trauma Activities • Paper Dolls • It’s Not My Fault • Letter to the Perpetrator • Abusers Know Kids • Trauma Narrative • Ungame

23. Psycho-education • What is Abuse/Paper Airplanes • Rate your Relationships • Dating Game • It’s My Body • Your Body Belongs to You • These are My Private Parts • Good Things Can Still Happen • Court Preparation • Safe and Unsafe Touching Coloring Book • Good Touch, Bad Touch Workbook • Explaining PTSD

24. Termination • Journey of Therapy • Graduation • Coping Plan • Safety Plan • Letter Writing • Goal Setting for the Future

25. Animal Assisted Therapy (AAT)

26. The Key to AAT…

27. AAT – Potential Benefits • Helps child relax and open up • Reduces resistance and engages child in therapy process • Builds relationship between child and therapist • Common interest to start with • Can help reduce fear and anxiety • Can increase self-awareness • Can increase motivation for regular attendance

28. AAT – Teaches Children • How to form healthy relationships • Enhances empathy and care-taking skills • Increases self-confidence • Assertiveness • Boundaries • Improved focus • Communication skills • Appropriate behaviour • Supports impulse control • Physiological self-calming • Lowering stress and blood pressure • Manage depression

29. AAT – Possible Pitfalls • Child doesn’t respond well to additional people • Handler interferes • Child becomes focused on the handler instead of the dog or therapist • Client perceives rejection if dog isn’t interactive • Dog can startle child • Setting limits • Allergies • Risk for injury (to client and/or animal) • Cultural Issues

30. Selection of Members • Referral process at DCAC • Intake paperwork • Psychosocial history • Behavioral checklists • Parent Report: Child Behavior Checklist • Self Report for Children: Trauma Symptom Checklist, Youth Self Report • Self Report for Parents: Adult Self Report • Suicidal clients

31. Groups • Psycho educational group • Preteen group • Teen group • Adult Survivor Group • Parent Support Group • Three Day Group • Children • Teens

32. Psychoeducational Group • Victims and siblings • School Age (up to 8 years old) • Male or Female • 6 weeks • Open group • 45 minutes

33. Psychoeducational Group • Week 1- Identifying Feelings and Coping Skills (“The Feelings Book” and Coping Skills handout) • Week 2- Feelings of Anger and Frustration, Deep breathing (“I was so Mad” and ) • Week 3 – Self Esteem (“I’m Gonna Like Me” and Flower Pot activity) • Week 4 – Unwelcome Touches (“Your Body Belongs to You” pages 1-5) • Week 5 – Body Parts (“Your Body Belongs to You” pages 6-12 and “It’s My Body”) • Week 6 – Safety Planning (“Please Tell!” and “Your Body Belongs to You” pages 13-16)

34. Preteen group • Ages 10-13 • Girls and boys • 1 ½ hours • 12 weeks • Closed group • All victims of sexual abuse • Weekly Journal Reflections

35. Preteen Group • Week 1 – Introduction, Safety, Rules, Icebreaker, Defining sexual abuse(What is Sexual Abuse?**) • Week 2- Identifying Feelings/Coping skills (Bag of Rocks) • Week 3- Processing Abuse (Paper Dolls**) • Week 4- Blame/Guilt (It’s Not My Fault*) • Week 5 – Triggers (Things that Remind me of the Abuse**) • Week 6- Parent Consults, Fun activity for group (Rock Painting, Beading) • Week 7- Relaxation and Self Care (Deep Breathing, Muscle Relaxation, Guided Imagery) • Week 8 –Self Esteem/Identification ( I Am So Much More*) • Week 9- Support people/ Relationships (Creating a safe person**) • Week 10- Resolution (Letter Writing) • Week 11- Therapy process (Journey of Therapy*) • Week 12 –Future/ Graduation (Guest Speaker or video, collage with caregivers) • * Activities found in Sueann Kenney-Noziska presentation* • **Activities found in Paper dolls and Paper airplanes**

36. Teen Group • Ages 14-17 • Girls and boys • 1 hour • 12 weeks • Closed group • All victims of sexual abuse

37. Teen group • Week 1- Introduction, rules, rapport (Never have I ever game) • Week 2- Rapport (MySpace/Facebook Pages) • Week 3- Identify feelings/problems (Bag of Rocks) • Week 4- Coping Skills (Self Care Calendar**) • Week 5- Defining Abuse (Paper airplanes**) • Week 6- Abuse (Good things can still happen/Flower pot**) • Week 7- Abuse (Twisted thinking, **pg 95) • Week 8- Abuse (Letter to the perpetrator) • Week 9- Court video and discussion • Week 10- Boundaries (Rate your Relationship**) • Week 11- Boundaries (The dating game**) • Week 12- Graduation and Goodbyes • * Activities found in Sueann Kenney-Noziska presentation* • **Activities found in Paper dolls and Paper airplanes**

38. Adult Survivor Group • Victims of Sexual Abuse prior to 18 years old • Must be 18 years or older • Male or Female • 12 weeks • Closed group • 1 ½ to 2 hours in length • Weekly Journal Reflections

39. Adult Survivor Group • Week 1- Introduction, Safety, Rules, Commitment to Therapy • Week 2- Abuse (Definitions and Paper Dolls**) • Week 3 – Identifying Feelings/Coping Skills (Bag of Rocks) • Week 4- Anger (Poster and Collage) • Week 5 –Shame and Guilt (It’s Not My Fault*) • Week 6 – Triggers (Things that Remind Me of the Abuse**) • Week 7 –Self Care/ Trust (Muscle Relaxation and/or Rock Paining) • Week 8 –Self Esteem/ Identification (I Am So Much More*) • Week 9 –Relationships (Discussion) • Week 10- Self Awareness (Goal Setting and Treatment Plan) • Week 11- Resolution (Letter Writing) • Week 12 – Future/ Graduation (Guest Speaker, Journey of Therapy*) • * Activities found in Sueann Kenney-Noziska presentation* • **Activities found in Paper dolls and Paper airplanes**

40. Parent Group • Confidentiality • Purpose of the group • Myths about sexual abuse • Education about sexual abuse • Learning why children don’t tell • Impact of abuse on parents • Coping with parent feelings • Impact of sexual abuse of children • Responding to their child • Information about abusers • Keeping children safe • Safety • Good communication • Parenting techniques (choices, limit setting, consequences)

41. 3 day group- ChildrenDay 1 • Nametags • Design folders • Rules • Ice breaker • Emotional Bingo game • Relaxation cards • Lunch-Movie • Playtime outside • Good touch/bad touch coloring book • Animal Assisted Therapy dog visit • Reunite with parents • Review the day, and assign Homework

42. 3 day group-ChildrenDay 2 • Name tags • Review Folder • Bag of Rocks activity • Paper Dolls activity** • Lunch-Movie • Playtime Outside • It’s Not My Fault activity* • Animal Assisted Therapy dog visit • Reunite with parents • Review homework, day activities and assign homework • * Activities found in Sueann Kenney-Noziska presentation* • **Activities found in Paper dolls and Paper airplanes**

43. 3 day group-ChildrenDay 3 • Name tags • Review homework • Write letter to the perpetrator (while parents meet with another therapist separately) • Share letter with parents • Lunch together- Movie • Parents write letter to child • Sharing of letters • Good things can still happen movie (Parents and children both watch the movie) • Children and parents make “good things can still happen” • Graduation

44. 3 day group-Teen and Pre TeensDay 1 • Magazine Cover folder • Nametags • Emotional Bingo • Yoga/Relaxation techniques • Sticky Situations activity** • Animal Assisted Therapy dog visit • Reunite with parents • Review day activities and assign homework • *Activities found in Sueann Kenney-Noziska presentation* • **Activities found in Paper dolls and Paper airplanes**

45. 3 day group-Teen and Pre TeensDay 2 • Nametags • Review homework • Bag of Rocks activity • Yoga/Relaxation techniques • Paper Dolls activity** • It’s Not My Fault activity* • Animal Assisted Therapy dog visit • Reunite with parents • Review homework, day activities and assign homework • * Activities found in Sueann Kenney-Noziska presentation* • **Activities found in Paper dolls and Paper airplanes**

46. 3 day group-Teen and Pre TeensDay 3 • Name tags • Review homework • Write letter to the perpetrator (while parents meet with another therapist separately) • Share letter with parents • Lunch together- Movie • Parents write letter to child (while teens process their feelings about sharing the letter with their parents in a separate room) • Sharing of letters • Graduation

47. Resources • Talking, Feeling, Doing Game • Ungame • Emotional Bingo • Feelings Checkers • Paper Dolls & Paper Airplanes • Creative Interventions for Troubled Children & Youth • Flip Flops, High Tops, & Cart Wheels • Group Work w. Sexually Abused Children Group Treatment for Sexually Abused Children It Happened to Me: A Teen’s Guide to Overcoming Sexual Abuse In Their Own Words: A Sexual Abuse Workbook for Teenage Girls My Body Belongs to Me It’s My Body Those are my Private Parts My Daddy is a Pretzel

48. Bibliography Bass, E. Davis, L. (1994). Courage to Heal: A guide for Women Survivors of Child Sexual Abuse. New York, NY: Harper and Row Publishers. Capuzzi, D. Gross, D. (2009). Introduction to Group Counseling. Denver, CO: Love Publishing Company. Chandler, Cynthia K. (2005). Animal assisted therapy in counseling. New York: Routledge. Crisci, G., Lay, M., Lowenstein, L. (1998). Paper Dolls and Paper Airplanes: Therapeutic Exercises for Sexually Traumatized Children. Indianapolis, IN: KIDSRIGHTS. Cohen, B., Barnes M., Rankin A. ( 1995). Managing Traumatic Stress through Art.  Baltimore, MD: The Sidran Press. Davis, L. (1990). Courage to Heal Workbook: For Women and Men Survivors of Child Sexual Abuse. New York, NY: Harper and Row Publishers. Davis, M, Eshelman, E.R. and McKay, M. (2000). The Relaxation and Stress Reduction Workbook, 5th edition. New Harbinger Publications. Grotsky L., Camerer C., Damiano, L. (2000). Group Work with Sexually Abused Children. Thousand Oaks, CA: Sage Productions Kenney-Noziska, Sueann (2010). Sexual Abuse & Play Therapy: Making a Difference One Technique at a Time. Presented at the 22nd Annual Crimes Against Children Conference. Dallas, TX.

49. Bibliography, cont. Knoff, H.M. And Prout, H. T. (2000). Kinetic Drawing System for Family and School: A Handbook. Los Angeles, CA: Western Psychological Services. Malchiodi, C. (1998). Understanding Children’s Drawings. New York: The Guilford Press. Oaklander, Violet., Windows to Our Children: A Gestalt Therapy Approach To Children and Adolescents. Highland, New York: Gestalt Journal Press, 1988. Omerod, Jan. (2007). May I pet your dog?: The how-to guide for kids meeting dogs (and Dogs Meeting Kids).Houghton Mifflin Company. Rubin, J. ( 2005). Child Art Therapy. New Jersey: John Wiley & Sons, Inc. Verdick, Elizabeth (2005). Tails Are Not for Pulling. Minnesota: Free Spirit Publishing.

50. Maggie Robinson, M.Ed., LPC-S, NCC, Registered Play Therapist mgarcia@dcac.org 214-818-2628 Kathy DuMond, M.Ed., LPC, NCC, Registered Play Therapist, kdumond@dcac.org 214-818-2652