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Running head: CHILD CENTERED PLAY THERAPY FOR SEXUALLY ABUSED CHILDREN

Child Centered Play Therapy for Sexually Abused Children

Nikki Smith LGSW, M.Ed.


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Abstract

This paper explores the impact of CSA on children as well as adult survivors. The paper

asserts the importance of early intervention treatment for children. Child centered play therapy

(CCPT) is suggested as an ideal therapeutic intervention model for children that have been

affected by sexual abuse and CCPT is examined in relation to CSA.

Keywords

Children, Sexuality, Childhood Sex Abuse (CSA), Play Therapy, Sex Therapy, Child Centered

Play Therapy (CCPT)

Childhood Sexual Abuse (CSA)

Trauma in childhood results when a child is exposed to severe physical abuse or sexual

abuse and feels betrayed, overwhelmed, and helpless. The child who has experienced

overwhelming life events develops coping mechanisms to keep him/her safe which can later lead

to dysfunctional behavior, mood disorders, personality disorders and/or addictions in

adolescence and adulthood (Namka, 1995). Sexual abuse can be so traumatic for children that

they suppress the event and it later resurfaces (Namka, 1995). Most children move through

developmental fears; however, the abused child carries their trauma related fears into adulthood.

Related fears include: fear of being hurt (physically or emotionally), fear of being alone, fear of

being kidnapped, fear of the dark, etc (Yancey, Hansen & Naufel, 2011, Brennan, 2006).

Victims of CSA have been found to experience a multitude of psychological, behavioral

and emotional concerns (in childhood or later in adulthood) such as: depression, anxiety, social

skill deficits, feelings of shame and guilt, school problems, post traumatic stress disorder, self
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harm behaviors, regression (such as bed wetting, etc.), developmental delays, eating disorders,

obesity, low self esteem, conduct problems, aggressive behaviors, withdrawn behaviors,

sexualized behaviors, insomnia, anger, suicide attempts, relationship problems, as well as others

(Wilson, 2009).

CSA is a pervasive societal problem. One in four females and one in seven males are

estimated to experience an act of sexual abuse prior to the age of eighteen (Misurell, Springer &

Tryon, 2010). Other research reports higher prevalence rates stating that 27-32% of females have

experienced CSA and 13-16% of males (Yancey, Hansen & Naufel, 2011). Based on research

from adults, Levanthal (2001) estimated that less than 10% of CSA is actually reported. The

under-reporting of CSA represents a societal denial of this significant, sensitive issue. Children

and Sex in the same sentence makes most people so uncomfortable they would rather ignore

the issue further stigmatizing and shaming the victims. CSA becomes the invisible population.

Disclosure of CSA can also be difficult. The main inhibitors to disclosure are related to fear,

shame, and self blame. Other barriers include: respect for authority, rigid gender roles, and the

taboo surrounding sexual issues, lack of acceptance and supportive adults, and a lack of language

to describe the event or events (Hunter, 2010).

In the CSA literature, attention has been given primarily to the specialized training

required of forensic investigators, training of allied professionals (nursing, teaching, etc.) with

the goal of increasing efficacy and confidence in fulfilling their role as mandated reporters of

suspected abuse, and empirically testable therapeutic approaches (usually some form of cognitive

behavioral therapy). What seems to be lacking is attention to the specialized training required of

those who guide the victims/survivors (Oz, 2009). Studies have suggested that CSA victims are a
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heterogenic group, varying in age, ability level, socioeconomic status, education, gender and

even outcome following abuse (Yancey, Hansen & Naufel, 2011).

Shame is an extremely powerful emotion that most CSA victims/survivors experience.

The childs internalized shame stems from fear. Shame experiences bring forth beliefs of I am a

failure and I am bad. Fears of being vulnerable, found out, exposed, and further humiliated

are paramount (Namka, 1995). Shame convinces victims to keep the sexual abuse a secret which

further intensifies the shame. Experiences that cause shame alter the childs basic trust of others

and consequently are the heart of much dysfunctional behavior (Namka, 1995). Children may

absorb some of the shameful energy of the person who committed the offense. Sexual abuse

causes children to feel dirty and damaged. Additionally the child who has been involved in

sexual experiences beyond their ability to comprehend often adopts difficulties creating

boundaries with others and themselves (Namka, 1995).

Need for Therapeutic Interventions for CSA

Research confirms that CSA can be devastating and the impact can cause a myriad of

emotional, psychological, and behavioral problems that can last a lifetime if not treated.

Ignoring the issue is not going to make it go away and furthermore even the child that

suppresses the abuse in childhood may have problems throughout their lifespan. There is a major

contradiction with the expectations of children these days as well. On one hand, they are growing

up in a hyper-stimulating, technology driven era where they are bombarded with knowledge

from the internet, they are over scheduled with activities and responsibilities and are treated like

miniature adults; on the other hand, they lack experiences, wisdom, and emotional maturity to

comprehend and make sense of the world around them. At times parents and other adults can
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regard children as resilient, and that belief may be true but it is not an excuse to avoid

confronting a childs issues particularly in regard to CSA. When the topic of CSA is

uncomfortable for adults, children can sense that and it further perpetuates the secrecy and

shame. Children can benefit from therapy to help them deal with the sexual abuse as well as the

other symptoms that may or may not have emerged from the CSA. Early treatment for children

will promote healing and can prevent further and future emotional and psychological damage.

Child-Centered Play Therapy

Adults communicate through language and words, although most of our communication

is non-verbal. Play is considered the language of children and it is an ideal treatment for children

that have been affected by CSA. Play therapy is a developmentally relevant treatment for

children and a key approach in resolving childrens psychosocial and emotional difficulties

(VanFleet, Sywulak & Sniscak, 2010). Cognitive Behavioral Therapy (CBT) as well as group

therapy has also been recommended for working with this population however I feel that

individual child centered play therapy is the best therapeutic intervention model for CSA

victims/survivors.

Children that have been affected by sexual abuse have among other things, lost their

sense of trust and control. In treatment models such as CBT and group therapy, the therapists

have the best intentions to treat the child in crisis but they are working on their own agenda and

in the therapists time frame. I feel as though the child centered model allows the child to have

control as well as work through issues at their own pace and at their own level of comfort, when

they feel prepared to process their trauma. Many treatment models for CSA victims can be

overwhelming for children when they are not ready to manage their trauma and therapists have
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pre-prepared and directed activities for the child to complete. The child is in a position, yet

again, to please the adult and lacking power and control in the situation. The therapist may tell

them that they do not have to do anything but they may still feel obligated to do as the therapist

says or suggests.

A strong therapeutic relationship is arguably the most important component and provides

a reparative experience in child-centered play therapy (CCPT) (VanFleet, Sywulak & Sniscak,

2010). Building rapport and a trusting therapeutic relationship is CCPT is vital especially when

working with children that have experienced trauma. CCPT allows the child to be in control of

his or her environment and therefore they are able to work through their issues at their own pace

as opposed to other play therapy modalities in which the therapist chooses the materials and asks

questions for their own agenda. Children are able to build trust with the therapist and test the

limits in a safe environment. Simply building a strong supportive relationship with their therapist

is progress. CCPT is a process and allowing the child to work through their trauma helps them to

develop a sense of control and mastery over themselves as well as their environment. Americans

fast paced culture demands immediate gratification but the process of therapy needs to be valued

and respected in order to be effective and long-term.

Client centered approaches are considered the most beneficial approach (Walker et. al,

2009). If play is a childs language, then toys can be thought of as the words. Through play

therapy the child can work through their challenges and issues using the toys (pre-selected by

therapist to facilitate emotional growth) that they choose, revealing their inner dialogue. The play

therapy toys represent the thematic stages in CCPT that children naturally progress through in

play therapy. These stages are a warm-up stage, followed by an aggressive stage, regressive

stage and finally a mastery stage (VanFleet, Sywulak & Sniscak, 2010). Some examples of
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warm-up toys include: art supplies, paper, clay, play-doh, toy cars, small plastic animals, toy

medical kit, and chalkboard. Communication toys are also important for the play therapy room

and they include toys such as a phone, megaphone, binoculars, and walkie-talkies. Aggression

toys include: inflated bop bag, dart guns, toy weapons, plastic soldiers, dinosaurs, rope,

aggressive puppets (wolf, dragon, monster, etc.), and foam bats or swords. Nurturance (family)

toys include: doll house and doll family, puppet family or animals, baby dolls, blankets, baby

bottles, kitchen set, child sized table and chairs, etc. (VanFleet, Sywulak & Sniscak, 2010).

Through play the child is able to test out various situations and behaviors in a supportive

environment (Webb, 1991). For children that have been sexually abused they may be in the

warm-up phase for an extended period of time, testing the limits and building rapport with the

therapist. The aggressive phase they will be able to work through their feelings of anger, loss of

control, power, shame, fear, etc. The regression phase allows opportunity for the child to nurture

and feel nurtured. In this phase play themes emerge around attachment, acceptance, love and

nurturance (VanFleet, Sywulak & Sniscak, 2010). They will be able to work through their issues

of trust as well. As regressive themes begin to fade and the child is gaining confidence themes

reflecting mastery surface. Play may reflect victories, pride, winning, etc. Problematic behaviors

show considerable improvement during this stage as well (VanFleet, Sywulak & Sniscak, 2010).

Unconditional positive regard and acceptance encourages the child to feel safe enough to

be able to explore their inner selves without censorship. In this environment children are able to

try out different roles, work through conflicting emotions and thoughts, and try to figure out

what the world is like. The child is able to form a relationship with the therapist, and through this

relationship they are able to develop trust, improve self-esteem, and self efficacy (Gil, 1991).
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In non-directive child-centered play therapy, the child is in control, within some gently

but firmly set limits. Most children often feel that they do not have control over situations in their

lives. During play therapy they are able to work through these experiences in an environment

that they are able to control. They can make the story be how they want it to be, they are in

charge of the outcome. This feeling of control is vital to their emotional development as well as

positive mental health. Children are able to use play as a means for developing problem-solving

skills, ways to relate to others, expressing their feelings, and working on their behaviors, all at a

safe psychological distance from reality (VanFleet, Sywulak & Sniscak, 2010).

Empathic recognition and reflection of feelings is crucial to most therapeutic intervention

and it is fundamental skill for CCPT therapists. Empathic listening is a skill of attunement,

beginning with the recognition of feelings and culminating in a response that actively conveys

the identified feelings in an accepting and nonjudgmental manner to the child (VanFleet,

Sywulak & Sniscak, 2010, p.26). The therapist does not ask questions in CCPT yet they are

keenly attuned to what the child is saying and doing and comment on it while recognizing the

emotions the child is explicitly or implicitly conveying (VanFleet, Sywulak & Sniscak, 2010).

When therapists reflect direct questions with empathic comments, the child learns to trust their

own instincts and builds self esteem and self efficacy (VanFleet, Sywulak & Sniscak, 2010).

The four basic skills that a CCPT therapist utilizes with children are structuring, empathic

listening, child- centered imaginary play, and limit setting (VanFleet, Sywulak & Sniscak, 2010).

Structuring includes setting boundaries, organization (time limits) and rules in the moment as

opposed to bombarding the child with various rules and regulations stifling their control and

creativity. Empathic listening is used throughout the play session from beginning to end,

allowing the child to take the lead as the therapist stays attuned with the child expressing their
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actions, thoughts, and feelings. Child centered imaginary play is significant in working with

children that have been affected by sexual abuse. In order to resolve the trauma of sexual abuse

in a healthy way, the trauma must be re-experienced through the retelling of the events in the

context of the relationship (Webb, 1991). Setting limits is important during imaginary play

especially with the CSA population. Children may want to take off their clothes for example. At

this moment the therapist would interject that In the playroom, one of the rules is that we keep

our clothes on. Then the child may pick up a doll and take their clothes off. The therapist would

continue to reflect for the child their actions as well as their feelings and to give permission to

the child in a non-judgmental way to validate their feelings and recognize their traumatic

experience. Imaginary play is directed by the child and the therapist shall participate if the child

invites them however, they are to bequeath creative freedom to the child and allow the child to

tell the story as the therapist in imaginary play is merely a prop (Gil, 1991).

Conclusion

Childrens sexuality in general is a taboo topic, and perhaps one of the most sensitive

issues relating to children and sexuality is children that have been victims of sexual abuse.

Childhood sex abuse (CSA) is a substantial problem in American culture and treatments for

young children should be implemented as an early therapeutic intervention. Age appropriate

sexuality education in combination with child centered play therapy will facilitate emotional

healing for children and possibly prevent future emotional and psychological damage.
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References

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