Trauma Exposure and CSA

A question often posed to us is, "how much do I try to get a child to talk about their sexual abuse?"

We are all operating under the mandate of "do no harm." When working with a child who is not spontaneously engaging in trauma exposure, how do we know when trauma exposure is indicated and how do we go about engaging the child? What about the possibility we may further traumatize, further ingrain trauma responses, or create new trauma pathways? What about colluding with trauma avoidance?"

Specialized training in the assessment and treatment of child sexual abuse and complex trauma are essential in preparing therapists for their work with children and families. However, even therapists with specialized training, education, and experience in working with children sometimes struggle with the determination of whether trauma exposure is indicated. I encourage therapists to consider beginning with assessment, psycho-education, skill-building, attribution retraining, and enhancing caregiver support/understanding.

Referring parents/caregivers as needed for their own services may facilitate their ability to support their child and engage in the child's treatment effectively. Engaging other closely involved individuals when appropriate and endorsed by your client may also prove helpful in assisting the sexually abused child in treatment. During the initial phase of treatment, the therapist's interactions with the child and their caregivers are likely to enhance their ability to identify the unique experiences, impact, and symptom expression of the client. Working with the child's caregiver and other individuals such as teachers who have the opportunity to observe changes in the child as well as possible symptoms, can be critical in identifying both progress in therapy and the child's means of coping. Ensuring that the child feels safe in therapy is essential and any work with others involved needs to be conducted in a manner that maintains the child's sense of safety within the therapeutic relationship.

Once assessment, rapport, safety (within and outside of therapy), caregiver engagement, and the initial skill-building groundwork have been accomplished, the question of trauma exposure becomes more relevant. It is likely the work during the initial phase of therapy results in a better concept of whether the child is in need of trauma exposure work. Most evidence-based therapies include some aspect of trauma exposure. If you are working with a child experiencing complex trauma or an active trauma, the first phase of treatment may be prolonged and the use of trauma exposure techniques may not be indicated (see link for National Traumatic Stress Network on complex trauma, below). The use of a Trauma-Focused Cognitive Behavioral Therapy Trauma Narrative technique is evidence-based and an effective tool in both assessing distress as well as beginning the work of trauma exposure (see link below for free online training on TF-CBT). The use of gradual exposure while telling the story will aid the therapist in determining if the child experiences distress. Inquiring into intrusive symptoms on an ongoing basis will also aid the therapist in determining the need for trauma exposure. Caregivers and teachers may give important information on possible intrusive symptoms.

If the child is able to tell their story without distress and there are no intrusive symptoms, trauma exposure may not be indicated. Instead, negative/false attributions and impact in other domains of the child's experience may be more appropriate targets of therapy. The trauma narrative will allow the clinician to assess for problematic cognitions, emotional responses, meaning, beliefs and general progress as well. Providing education to the child and caregivers as to why trauma exposure may be helpful will also likely increase the effectiveness of the intervention. Gradual (never forced or pushed upon the child) and responsive interventions beginning with less distressing targets to create mastery, with ongoing assessment and gentle encouragement, are much less likely to create undo distress or new trauma pathways. When engaging in trauma exposure interventions, it is important to ensure that any distress experienced is tolerable within the session and is addressed prior to the end of the session, providing time at the end for debriefing and positive/pleasant interactions/activities.

It has been my experience that therapists concerned about creating distress or trauma pathways are quite sensitive to the experience of the child to the trauma narrative and are responsive to the child's need for relief from distress. As we all know, if you are unsure, consultation and supervision are essential — we all benefit from excellent ongoing training and consultation; therefore, included, below, are some resources for you!

Many thanks to Tambra Donahue, Monarch CAC in Lacey, for this "Tip" and resources.