Sheila Mansell, Ph.D.
Therapists providing services to individuals who have been sexually abused encounter many distinct problems that require consideration. This paper reviews the therapy accommodation literature and presents selected results from an international survey of therapists involved in providing these services. The descriptive data from this study revealed that many respondents modified a range of traditional therapies and used additional treatment components when working with clients who had been sexually abused. Respondents also reported experiencing distinct challenges with adapting therapy techniques to the clients cognitive and communicative abilities, accessing materials, securing social, collegial, and financial support for their clients treatment, and negotiating with different service systems (e.g., child welfare, mental health, and disability services). A composite case illustration outlines some of these issues and therapy modifications.
Historically, therapy for people with developmental disabilities who have been sexually abused has often been inaccessible, unavailable, and inappropriately adapted to meet their needs (Mansell, Sobsey, & Calder, 1992). In more recent years as the dual diagnosis field has expanded there has been growing acknowledgement of the mental health problems associated with the heightened vulnerability of this group to sexual abuse. This acknowledgement is reflected in the increasing number of reference materials, literature resources, research, and training opportunities that are focused on strategies to address the mental health issues of people with developmental disabilities.
Providing therapy to people with developmental disabilities who have been sexually abused presents therapists with several important considerations. One such consideration involves the complex evaluation process involved in determining the appropriate diagnoses of mental health and behavioral concerns (Charlot, 1998; Lowry, 1998; Mayer & Poindexter, 1999; Myers, 1999; Sovner, 1986). The use of comprehensive clinical assessments that are based on multiple sources of information is often necessary. These sources may include case records, medical/biological tests, behavioral observations, client and staff interviews, and formal measures of dual diagnosis, aberrant behavior, and personality (Reiss, 1994). Therapists need to conduct careful, ongoing, and thorough evaluations of a clients comprehension and communication abilities, access to social support, medical conditions and medications, and documented response to the sexual abuse (Mansell & Sobsey, 2001). Professional liaison, with client permission, and careful observation of client responses both within and outside treatment can provide necessary information that informs therapists about therapy efficacy. Therapy approaches need to be carefully chosen and modified to accommodate to the clients cognitive, developmental, communication, social, emotional and mental health needs to maximize therapy efficacy (Fletcher 2000; Hurley 1989; Keller, 2000; Lynch, 2000; Prout & Cale, 1994; Prout & Strohmer, 1994).
Westcotts (1992) survey of child abuse professionals working with children with developmental disabilities indicated that this practice presents therapists with some unique challenges and considerations. Respondents indicated that they encountered problems that included: lack of interagency cooperation, unwillingness of various parties to take responsibility for addressing the mental health needs of these children, antagonistic responses from family, some families refusal to recognize the childs disability, and inability to obtain adequate resources and specialist advice. Respondents reported therapy accommodation difficulties such as finding the right level at which to work with the child, assessing a child comprehension, and making allowances for the childs reduced attention span (Westcott, 1992).
Therapists Accommodations Survey
Although there has been a long case study tradition in this literature, there are few descriptive studies of professionals specific therapy practices, the problems they encounter, or what factors may influence their use of particular accommodations or treatment components with clients who have developmental disabilities who have been sexually abused. This study used a survey method to obtain descriptive information about professionals training and experience; the specific therapy techniques, accommodations, and treatment components these respondents used; and the difficulties that were encountered by these professionals. Selected results will be presented here; the complete results of this survey are reported elsewhere (Mansell & Sobsey, 2001).
Potential participants from the United States, Canada, Europe, and Australia were selected for inclusion because they were either known to possess expertise in this area or to provide therapy services to people with developmental disabilities, or to have professional affiliations that would promote appropriate survey distribution to appropriate individuals. Participants were contacted by mail, sent a cover letter describing the study, a survey, and a self-addressed, stamped envelope. All survey responses were confidential and respondents were asked to preserve their clients confidentiality by avoiding the use of any identifying information. Of the over 300 surveys distributed 105 were returned with usable data. Some surveys were returned untouched and therefore, it is difficult to determine either the exact response rate or the representativeness of the respondents. The responses of a self-selecting, non-random sample may not be representative of professionals providing this service, who chose not to respond, or were not targeted or reached as potential participants.
In the survey, respondents were asked to describe their professional training, education/discipline, and amount of experience. Respondents were also asked to identify and describe the therapeutic accommodations, approaches, and the specific therapy techniques or components that best described their practice when they treat sexual abuse related issues. Also respondents were asked to describe the difficulties they encountered when providing this service. Respondents could use multiple categories to describe therapeutic accommodations, approaches, and the specific therapy components they used in their practices.
Training and Experience
Briefly, the summarized results of this preliminary study suggested that respondents had considerable professional training and experience in their chosen disciplines. Respondents had a mean of 11.5 years (SD = 7.6 years) experience in their reported discipline and many respondents were trained in more than one discipline. There was a strong multidisciplinary orientation in this sample with representation from the medical, mental health, and mental disability disciplines (e.g., respondents included psychiatrists, psychologists, social workers, professors, art and behavior therapists, nurses, occupational therapists, etc.).
Therapy Approaches and Modalities
There was enormous diversity in the therapy approaches, modalities, accommodations, and treatment components that respondents reported using. A large majority of respondents identified their therapeutic approach as cognitive behavioral (62%). Fifty-six, fifty-four, and forty-nine percent of the respondents identified their therapeutic approach as behavioral, eclectic, and client-centered, respectively. Almost all respondents identified using a variety of therapy modalities including individual, group, family, educational, and expressive.
The specific accommodations described by respondents included the use of concrete language, plain English, less verbally-oriented therapies (play, art, sand, dolls). Respondents reported providing additional time for the client to respond, learning the clients non-verbal communication style (such as the use of non-verbal and idiosyncratic language and gestures), and learning the clients verbal communication style (such as the use of intonation, articulation, speech patterns, idiosyncrasies). Other accommodations included the use of music, movement, concrete materials and models, video demonstration and feedback. Respondents also reported using shorter, more structured and goal focused sessions, environmental accommodation, on-site visits, behavioral incentives, facilitated communication, behavior practice and role play, repetition, and providing support to the clients staff. Accommodations that were reported by over 80% of respondents across all categories of client disability included learning the clients non-verbal communication style, providing additional time for the client to respond, learning the use of concrete language, and plain English.
Many respondents indicated they used components to enhance therapy efficacy. A large proportion of respondents reported that they worked systemically and enlisted parents/guardians or staff as support where appropriate (77%), used pre-therapy preparation or relationship-building techniques (66%), and psycho-educational techniques and repetition to teach specific concepts (60%). Approximately half of respondents reported using more directive approaches to maintain focus and structure in therapy and using educational approaches to teach clients an affective vocabulary.
Many respondents also indicated that they used therapy components to help reduce vulnerability to sexual abuse. Over sixty percent reported using social skills/sexuality education, sexual abuse risk reduction education, and assertiveness training, respectively. Forty-nine and forty-one percent of respondents reported that they used components to enhance communication skills and in-vivo training to promote concept generalization, respectively.
Many respondents indicated that they used specific therapy components to address their clients sexual abuse related effects. Eighty-six, seventy-one, and sixty-one percent of respondents indicated that they treated poor self-esteem, developmental disability issues, and used behavioral approaches for secondary behavior problems (e.g., inappropriate sexual or aggressive behavior), respectively. Thirty percent or less of respondents reported using empathy training, gentle teaching, and teaching about boundaries, and educating service providers.
Problems encountered by over fifty percent of respondents included adapting communication style, inadequate professional and financial support for therapy programs, and eliciting cooperation from staff or family members for therapy. Thirty-seven percent of respondents reported difficulties adapting the therapists communication style to meet clients communication and comprehension needs for assessment purposes. Thirty-three percent of respondents reported difficulty flexibly and creatively matching therapy techniques to client needs. Approximately one-fifth of respondents reported having difficulties obtaining adequate psycho-educational or resource materials, access to communication alternatives for therapy, securing appropriate sexuality educational and testing materials. They further reported inadequate collegial validation, specialized communication training, and supervision. Other problems they reported included overcoming professional, attitudinal, and financial barriers, working with the legal system, securing cooperation from the clients system, and maintaining confidentiality.
Overall, the diversity of therapy approaches, modalities, and accommodations reported by this sample appear to be consistent with the recommendations from the literature. Concerns noted by professionals in this study appear to correspond to, and expand on, some of the issues noted in Westcotts study (1992). As in that study, respondents in this survey reported a range of difficulties that included actually adapting therapy and overcoming various educational, collegial, financial, and systemic obstacles. This finding underscores the importance of professionals from various disciplines obtaining specialized disability-related training, supervision, and consultation. Ongoing study and advocacy are needed to ensure people with developmental disabilities receive appropriate treatment. A case illustration from the authors private practice follows.
This case illustration represents a composite of many different therapy clients and is not intended to portray a specific individual. This case illustration gives a general outline of this therapists approach and the therapy accommodations and components that are commonly used, and some of the difficulties encountered.
Tinas background had been marked by substantial emotional and sexual abuse. She was 18 years old and reported she experienced chronic sexual abuse at the hands of her mothers boyfriend who lived in the family home. At the time of the initial referral Tina was living in a supported living arrangement away from her family and was having substantial coping difficulties, anxiety, irritability, and anger outbursts.
At the time of referral Tina already had service providers involved with her and appropriate releases of information were obtained to talk with those working with her at home. Limits were established with service providers early on about preserving Tinas privacy as much as possible. Working with Tinas system of service providers was a necessary consideration to her therapy. Their cooperation allowed there to be a responsive team supporting treatment goals that could address misunderstandings and outline areas for support needed outside sessions. Service providers were also taught about the functions of her behaviors. Her anger and irritability were important reasons for her referral but service providers also needed to understand that these were also symptoms of her depression. Service providers were also taught how to help Tina practice coping strategies that supported her ability to generalize skills she was learning in therapy.
Tina was initially referred to the psychologists private practice for a preliminary assessment to identify her mental health and behavioral issues and her ability to participate in therapy. As part of most such assessments I conducted semi-structured and structured interviews with those working closest with Tina to obtain preliminary information concerning her personal/family and other relevant history (as she had difficulty providing a coherent history). A document review is conducted to determine Tinas history and level of functioning and, when necessary, referrals were made elsewhere for additional relevant assessments. I also used formal dual diagnosis, adaptive functioning, and behavioral measures to obtain indicators of Tinas current emotional functioning and behaviors.
The results of the interviews file reviews, and mental health assessment revealed that Tinas level of cognitive functioning fell in the mild range of mental handicap. She was described as showing mild expressive language delay and moderate receptive language delay. She also exhibited behaviors that met the DSM-IV diagnostic criteria for Post-Traumatic Stress Disorder (PTSD) and Dysthymic Disorder. Tina exhibited a substantial history of sleep problems, nightmares, irritability, and anxiety. File review revealed that she had been assessed at a hospital sleep lab and the results did not support any sleep, nightmare or other neurological diagnoses. Tinas sleep disturbances appeared to be better accounted for by her longstanding trauma-related anxiety, coping difficulties, and depression.
Many of the early sessions were devoted to teaching Tina about the purpose of our visits, clarifying our roles and responsibilities, establishing goals, and teaching about feelings. Tinas treatment goals included sleeping better and being less anxious and angry. She was frequently irritable, noncompliant, and verbally aggressive with her service providers and was consistently facing consequences for her behavior. She also wanted to heal from her sexual abuse. With social support and a desire to heal Tina proved to be a good candidate for therapy.
Tina used a lot of behaviors to express her feelings and had few words to describe her feelings or needs. I consulted with her service providers about the possible communicative functions that some of her more aggressive and defensive behaviors served. I emphasized the importance of helping her develop the vocabulary and assertiveness to communicate. Several sessions were devoted to teaching her a vocabulary for feelings. For some time Tina had difficulty understanding the distinction between physical and emotional hurt but the distinction eventually was made. Later a scaling technique (using 0 to 3) was used to describe her level of emotional intensity and emotional changes. This technique was introduced to Tina and her service providers to help her generalize what she learned in therapy. The scaling technique proved to be a powerful, concrete, therapeutic technique that allowed Tina to have more control and to be less overwhelmed. She had a version of the scale in her wallet and at home. She initially needed prompting to use it but eventually used it independently. Service providers also found that this technique gave them a gauge for her feelings and needs.
As noted, Tinas expressive language was better developed than her receptive language and she often appeared to understand more than she did. Throughout therapy I carefully assessed Tinas comprehension of the language used. Sometimes Tina would use language or terms that she had been exposed to but did not understand (e.g., panic). Assessment of her comprehension needed to be done carefully. I used a one-down position to avoid leaving her feeling as if she was being tested. I framed this questioning as her teaching me what she meant. Sometimes I would use language that was too abstract for Tina. When these situations arose I would reframe the situation and assure Tina that the problem with understanding was not hers, but mine as I didnt say something the right way so that she would understand. I took responsibility for my error, apologized, and thanked her for her patience with teaching me. In these situations I emphasized that sometimes I was slow to learn how to say things the right way and that I needed her to be patient when she was teaching me. She seemed to enjoy the novel and positive feeling of seeing herself as someone who could teach others.
Tina had a tendency to agree to requests or recommendations, but would not always follow through due to language, memory, and comprehension problems. Misunderstandings sometimes occurred during treatment and took surprising forms. A notable example of this difficulty occurred following consultation with her physician. She recommended using a short-term trial of antidepressants to relieve some of Tinas anxiety and depression symptoms. Due to lack of clarity on my part, confusion on the part of Tina and the service providers, and my failure to recognize this early, she declined to make her physicians appointment. A few weeks later when I inquired about her progress with the medication she explained that she did not go to the doctor. The service provider said Tina asked about using drugs after her last session and that they assumed she was talking about street drugs. Tina later said she had been told by her service provider to Just Say No to Drugs because these could kill her and refused to go to the doctor. Once this misinformation and angst was cleared up with all parties, Tina went to the doctor, learned about her medication, and started taking and responded positively to the antidepressant she was prescribed. Her reduced depressive and anxiety symptoms improved her ability to engage in therapy and the increased communication with her service providers improved my ability to gauge where Tina was making progress and where she and the service providers needed more assistance.
Support from Tinas service providers improved her sense of control over her symptoms and coping abilities and set the stage for addressing the effects of her abuse in treatment. Tina could decide if and when she wanted to talk about the abuse. The specifics of her abuse experience were not the sole focus in treatment, instead the emphasis was placed on helping her understand how her experiences affected her feelings, express these feelings in safe healthy ways, recognize her strengths, and practice her coping skills. Later, therapy sessions would focus on additional consultation with service providers about teaching assertiveness, promoting self-esteem, social skills and making friends, using feelings as a guide when meeting other people, communicating about needs and wants, grieving and loss, and establishing boundaries. Sessions were shorter to accommodate her short attention span. At each session an initial review was given of the previous sessions content and some of the feelings that were talked about.
Cognitive behavioral strategies proved helpful with Tina. Anger management and modified relaxation techniques were used both in and out of session to promote generalizability across situations. Later on, educational approaches were used to help Tina learn about sexual and emotional abuse, boundaries, sexuality, and assertiveness. Concrete strategies using visual materials, repetition, and incidental learning situations were essential.
Since therapy, Tina exhibited fewer behavioral, sleep, depressive, and anxiety-related symptoms and no longer takes anti-depressant medication. Tina has clearly benefited from therapy and has made progress in understanding the emotional consequences of her sexual abuse and is learning emotional self-regulation and assertiveness skills, a vocabulary for her feelings, and means to communicate about, and practice letting others understand, her needs. Despite considerable repetition, Tina still has difficulty grasping the concept that abuse and exploitation do not always entail violence. Although Tina has made great progress in therapy and is showing far fewer symptoms and greater coping abilities than prior to therapy she requires ongoing service provider support to initiate strategies she has learned and to maintain the gains she made in therapy.
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For further information:
Sheila Mansell, Ph.D.
6318 112th Street
Edmonton, Alberta T6H 3J6, Canada