CHAPTER VII

Child abuse treatment is multifaceted. Transmission from one generation to the next generation of abusive behavior is well established through the mechanisms of imitation (identification with the aggressor) and chain conditioning and sustained by prevailing cultural beliefs and environmental conditions. Child abusers were abused as children and are repeating the same behavioral patterns as their caretakers. (Bettleheim 1950; Grogan 1988; Porter 1988; Steele 1976; Thomas 1981). Additionally lack of information about child rearing, nutrition and child development pervades the world of the child abuser. (Hovde 1982-. Hovde 1985; Jackson et al 1978) Child abusers are socially isolated, exhibit role reversal, and are emotionally immature. Often child abusers are describing as being impulsive and repressed at the same time with bouts of uncontrollablerage. They also have a distorted perception of the abilities and skills of children. Furthermore they are repulsed by breast-feeding and avoid any information regarding childbirth. Child abusers as a group believe that a child of nine month of age should be able "To quit the crying" when told to do so. These characteristics indicate that therapeutic intervention with child abusers requires family reconstruction in all aspects of their functioning.

Additionally, the emotional drain and often persistent resistance to change, and the cultural reinforcement of abusive child rearing practices require that mental health workers who treat child abusers to actively guard against burnout by involving themselves in ongoing support groups.

Since the enactment of reporting laws one of the issues that a therapist must encounter is the response of the patient who has disclosed in therapy abusive behavior that the therapist must report to the legal authorities. In short, will the patient flee treatment and will the legal system be so disruptive that more harm will be done by reporting than not.

Yes, patients do f lee treatment when they are reported and yes, there are and continue to be legal systems involved in the reporting that cause far more damage to the abused and the abuser (Tyler et al 1984). No, mandatory reporting does not always have to result in patient flight or legal brutalization of the family.

Harper and Irvin (1985) suggest the following guidelines for reporting:

1. One who has the data about abuse must report. Never expect another to report your case. Avoid giving the impression that denial is characteristic of your work.

2. Report whenever you suspect a child to be at risk. Do not rationalize confronting parents’ denial.

3. Use self-scrutiny before reporting.

4. Inform parents with candor and concern.

5. Consult with the clinical team if you in group practice and if in private practice consult with colleagues in gray area case.

In their discussion of mandated reporting Harper and Irwin (1985) stated:

The data presented here indicate that when the reporting is done in the context of ongoing treatment, the f eared f light is not 1ikely to occur, even in families that have repeatedly fled other services. Moreover, in many cases the act of reporting, as a clinical intervention, is not only free of risk, but contributes to the work at hand. Reporting can relate both parties more clearly to reality, helping clinicians and parents together to avoid wishful thinking and denial with regard to a major threat to the child. (p. 554)

 

Newberger and Hyde (1979) found that parents respond to reporting with relief that a difficult problem is being dealt with in a straightforward way.

It is important that the therapist establish knowledge of and rapport with the legal justice system to be able to provide the abuser with information about the process. Also, in order to use the mandated reporting as a therapeutic tool, and to build trust with the patient it is often best to report to CPS in the presence of the patient and to advocate (when appropriate) for the abuser in their presence (Hymen 1988; Lundeen 1988).

Harper and Irwin (1985) concluded that mandated reporting in the context of a clinical relationship could be an important clinical instrument.

Implicit, in reporting and working with child abusers, is the need to develop empathy and understanding of individuals who commit acts against children that a time are repugnant to the therapist. Working with abusing individuals and family systems is difficult and requires therapist to constantly update their own skills and attend to their own mental health.

There are a number of therapeutic procedures used with child abusers: Modeling/Imitation; multi Generation; Support Systems; Art Therapy; Group Treatment; Home Visits; Martial and/or Family Contracts; multi Discipline/Systems Approach; Rage Reduction/ Systematic Desensitization of Respondent and Operant Behavior.

In discussing the dynamics of child abusers under treatment Savino and Sanders (1973) stated:

The therapists are a child psychiatrist and a public health nurse- Thus, the group members have both a "father" and a "mother" model. When parents first enter the group, they usually show strong feelings of rage toward society for "causing" them to be in this predicament (4). They usually direct this anger at the pediatrician who made the initial diagnosis and the social worker who worked with them during the court proceedings. Many look at the social worker as someone who has control over their future; it is she who must ultimately write a report recommending continued placement or return of the child to the home. After a few sessions, the couples become less angry and the group process moves in two directions. One aspect is dealing with the resistance the parents feel toward discussing the problems, which ultimately led to the abusive act; the other deals with being a parent. The parents who benefit most are those finally become comfortable enough to talk about the abusive acts. The types of difficulties these parents have demonstrated are longstanding isolation, poor peer interactions, severe marital conflict, and life-long patterns of inadequate family interaction.

All the families’ display marked deficiency in their knowledge about being parents, so the second focus in the treatment group or program is on childcare. For example, during one session all parents agreed that a nine-month old baby should be able to stop crying when told to do so. The instruction includes normal physical and emotional developmental patterns feeding, toilet training, discipline, sibling rivalry, and the like (p. 482).

Steele and Pollock (1968) recommended giving the parent’s sympathy, understanding, and attention (rather than paying most attention to the child). Steele and Pollock encouraged the parents to use them as substitute parents, and they made themselves available to the abusing parents 24 hours a day.

Eventually they encouraged the abusing parents to establish rapport with their own parents and with other people in the community. The parents eventually began treating their children as they were treated by the therapists.

Holter and Friedman (1968) suggested using a homemaker model. The homemaker goes into the home to establish rapport with the mother and to assist her in caring for the children. This gives the parent a friend as well as a model to imitate.

In discussing the importance of establishing rapport with child abusers Fonatana (1976) commented:

The establishment of a relationship with the paraprofessional in the program was the most frequently cited component as being most helpful in enabling the acquisition of specific skills for greater internal control and self-direction (p. 763).

The therapist functioning as a model and friend to child abusers has been one of the most important aspects of the therapeutic process in the author's experience. Time after time the author has heard abusing parents state "they never had a friend before", and/or "I have never had anyone to talk to before." it is extremely important though that the abusing patient be aware that the therapist is doing their job. The friendship is limited to the professional relationship, and that the ability to form friendships can and must be extended for them outside of the therapy session.

The authors’ most successful cases are those in which grandparents, parents and children have all been involved in the therapeutic process. The process of chain conditioning has been evident when observations have been made of the same family interacting in psychotherapy together. In the attempting to establish extended family ties the author has learned that relatives have not been a desirable source if they have not been through therapy themselves or will not consent to on going extended-family therapy. When relatives consent to on going multi-family therapy, progress has been phenomenal.

Community resources can be an extremely valuable asset, especially with single parent mothers who are on welfare. The single parent mother, who is relying upon Aid to Families with Dependent Children (AFDC) for life support system is also eligible to attend the local junior college and receive various grants for going to school, childcare, and transportation. At Solano Community College, the women's reentry program is extremely important in helping the single parent mother in adjusting to college. Not all the mothers that attempt to re-enter college will be successful.

Gladaton (1965) urged the parents to look to their own past experiences as sources of abusive feelings rather than blaming the child as the only source.

In discussing the use of art therapy with abused children Stember (1977) commented:

The drawings of abuse and neglected children are a cry for relief, a plea for a chance to grow. Through art therapy. I try to reach underlying feelings of helplessness in a child in order to help the child communicate freely and grow emotionally. By going directly to the home, an art therapist can help a child cope with his daily problems, assist parents in understanding their child, and play a key role in strengthening the family (p. 5).

In discussing the resistance of child abusers and the use of art therapy Schornstein (1977) reported:

The response to drawing is usually less defensive than to the traditional clinical interview. It is very rare that an individual will refuse to take part in the drawing exercise. Some drawings show situational problems or personality rigidity and isolation, chaos in the home and so forth. We have been able to identify siblings who were at risk. Drawing also clarify the perpetrator when his identify has been unclear. These drawings tell a myriad of things about the individual and his family:

1.Their perception of the family-who is included, left out-what extras are included.

2. What the family is doing? Are they interacting: if so, in what manner? Are they separated by barriers?

3.Things that are drawn that are unrealistic, such as stick figure, children drawn much older or younger than their chronological age.

4.Structure of drawing-unsteady ground line (p. 6).

The author has found that art therapy coupled with projective sensory association has been the technique that enable child abusers and abused children to express the repressed hurt and rage that hew been buried since early childhood.

The Author has developed an intake procedure utilizing art therapy and projective sensory association. The Draw a Picture of Self (DAPS). Draw a Picture of the Family (DAPF), and the Projective Sensory Association (PSA) is effective tools in developing the diagnosis of a patient, tracking personal and family dynamics, stimulating the patient to draw and verbalize problems, and to help the abused child to non-verbally communicate their experience.

I. Administration

A. During the first or the second session with the patients/family give them two of the DAP/PSA 001 each.

B. They are then instructed to draw a picture of themselves. Patients will ask numerous questions as to how they should draw the picture. Just say draw of picture of yourself/family with out other instructions. You want to provide the patient with as little structure at this point as you can. If you are working with a family pay very close attention to the family dynamics as they draw together. Of ten one of the parents will become quite intrusive on a child drawing, frequently telling them that they are drawing wrong.

C. After the patient has completed drawing a picture of self/family then have them complete the PSA associated with the picture. Instruct them to write down a word that they associate with the drawing of themselves in the sense of (say the sense). Additionally say this for each item of the PSA.

1. Vision

2. Sound

3. Smell

4. Taste

5. Touch

6. Temperature

7. Movement

8. Mood

9. Title

10. Weight

11. Height

12. Why you came

13. Birth date

14. Today date

15. Name

Instructing patients to identify their favorite foods, animals, pets relatives, etc. can provide very cathartic data.

D. After the DAPS and PSA are completed then repeat the procedure with the DAPF with the additional instructions to place the name, relationship to the patient, and age of each person or pet in the DAPF.

E. After the patient completes the DAPF then have them complete the PSA associated with the DAPF.

F. If the DAPS, DAPF, and PSA are administered in the group intra-family, or inter-family setting the members can be asked to identify either the group or specific individuals in the group as the subject of the DAPF or PSA.

G. Once the DAPS, DAPF, and PSA are completed, the therapist collects them and then ask the patient(s) if he/she would like to discuss them. Often in the group setting where a patient is the subject of the groups drawing, each group member is ask to discuss their drawing.

II. Analysis of the data is a two step process: feedback from the patient and interpretation by the therapist.

A. First always queries the patient about the drawing itself. Often while explaining their DAPS/DAPF the patient will reveal their insecurities, extremely sensitive data about themselves and their families.

B. Secondly, the therapist provides the patient with feedback as to how the therapist interprets their drawing. Try to allow enough time in the session to provide the patient with feedback at the session that the DAPS/DAPF is administered.

C. Factors to be considered while interpreting the DAPS/DAPF.

1. What physical parts are present and which ones are not?

2. Is any part out of proportion in relationship to the rest of the body or background.

3. Does the drawing approximate what is reported in items 10 and 11 of the PSA.

4. Is the drawing at an age level expected from the patient.

5. What is the position on the page.

6. What is the sex identity in the drawing.

7. What types of clothing are present or absent.

8. What type of profile is presented.

9. What is the body language of the drawing?

10. What activity, if any is the person/family involved in.

11. How clear and strong is the picture?

12. How distinctive are the features.

13. How much distortion is there between the patient present condition and how they represent themselves in the drawing.

14. Does the patients include themselves in the DAPF.

15. Who do they include in the drawing of the DAPF.

16. Who is in the background or foreground of the DAPF.

17. What are the positions of each family member relative to each other in the DAPF.

18. Who is touching and who is not in the DAPF.

D. Factors to be considered in interpretation of the PSA.

1. What senses is the patient unable to provide a word.

2. What is the general theme of the words.

3. What are the contradictions between the general theme of the words and the patient-presenting problem.

4. Items 9 through 16 provide cognitive functioning indices dealing with personal and time orientation.

III. Discussion:

The use of the DAPS, DAPF, and PSA provide the therapist with a permanent, written record of the patients present self/family identity, motor skills, verbal skills, perceptual distortions, orientation and demographic factors. Additionally the patient is required through a non-threatening medium to focus upon themselves and their family. All acquired learning comes through the senses. The stimulation of the senses can be used to elicit from the memory of the brain data that can be used and integrated into the patients here and now behavior. The DAPF can also be used to begin the construction of a Genograms. Often the distances between family members in the DAPF clearly identify the individual boundaries and triads. The purpose of the projective sensory association has been to bring to consciousness repressed material via the cumulative associations of each sense modality. Memory recall is enhanced by this technique. When the abuser was programmed to repress from consciousness the pain they were experiencing, the stimuli impinging upon the sense modalities was also repressed. The inhibition process is a diffused process incorporating not only the specific pain felt but also all information acquisition occurring via sensory stimulation and cognitive processing.

In discussing art therapy as a tool for the treatment of abused children Yates, Beutler, and Crago (1985) stated:

Art is an expression of the child's inner reality. Young children draw what they know rather than what they see: A portrait of mother is the same whether she poses for it or not. Each picture, be it scribbled in haste or meticulously traced, is a statement of the child's internal knowledge as colored by the affective state and associations. Tasks such as drawing a person or drawing the whole family doing something have become valued techniques in the armament of child evaluators and therapists. (p. 183)

Segal (1969) suggested a group approach as well as a homemaker model. Therapist team consisted of a male and a female. The team worked with abusing couples and encouraged them to break out of their isolation and begin satisfying their needs through other couples in the group. The homemaker model suggested was in a foster home where the abusing parents observed the foster parents taking care of the children.

Wasserman (1967) began working with groups of abusing parents and their families. The parents were encouraged to begin satisfying some of their needs through the other parents in the groups and were better able to handle problems.

Parent’s Anonymous has been using parents groups as their main system of treatment. Recently Parents Anonymous began to use family groups as a method of treatment. In discussing Parents Anonymous new program of family groups, Adoms (1976) reflected:

Modeled after the two-year-old Richstone Program in Manhattan Beach, California, this program envisions tying in with Parents Anonymous (PA) Chapters throughout the country.

"Beginning a children's group in adjunct to a Parents Anonymous Chapter can be very explosive," said Allene Goldman, sponsor of the Center. "If you are not careful, you blow the entire PA Chapter."

Speaking from experience, Goldman, who began as the sponsor for a PA chapter in California, said. "I became concerned about the children of these parents and recognized an ideal opportunity to enhance the overall therapeutic setting by involving the kids."

The concept sounded logical enough but it was not so easy to sell. Goldman explained that the parents became very frightened at the thought of a professional meeting with their children. "I approached the group with the subject ... not one parent came to the next meeting. Finally they returned to the chapter with their children but they returned to the chapter with their children but they refused to talk about it - in essence, I got their silent approval." She said, it was a very touchy and an emotional decision for these parents. At first they were certain that he idea would fail."

But it did not fail. Furthermore, two years later, it is surviving and appears highly successful for both the parents and the children. The parents were not required to bring their children but they do. They all eventually come. As a result of the Richstone success, Goldman was anxious to initiate similar programs elsewhere based on what was done at Richstone.

The PA philosophy is a part of the children's group - that is, it is non-threatening place for the children to go - to play or to talk.

Under the supervision of a lead teacher, volunteer students work with the children. Goldman explained that the therapy focuses on the parent and the child relationship. "We try to stress the strengths inherent in the relationship, rather than the weaknesses." There is an emphasis on marriage and family counseling (p. 3).

Timmons-Mitchell (1985) used a number of techniques outlined in Ray Helfer's book Childhood Comes First: A Crash Course in Childhood for Adults (1978) with a group of seven abused children. Those techniques were (1) sensory training; (2) self-acceptance; (3) self-control; (4) responsibility;(5) accepting one's own feelings; and (6) relating to others. Timmons-Mitchell concluded:

All of the constructs underlying Childhood Comes First were found to be adaptable into tasks for use with children who have been abused. … learning simple behavioral contingencies was extremely difficult for this group of abused children. ... in the present group, one leader was insufficient to provide the degree of supervision required for the children to learn to trust others and cooperate in a group within a 6 - month period. Alleviating the time and manpower limitations of the present group would be useful to see whether this approach can be more widely employed in working with children, as well as adults who have been abused.

Home visits with the father present have been the most successful procedure for involving the father in therapy. The author has found, once some common ground of communication has been established which is non-threatening to the father, that he will expose deep-seated feelings of loneliness and hurt.

Home visits have been essential to the treatment of child abusers in the author's experience. First, this technique enables the therapist to have experiential information of the abuser neighborhood, home, house maintenance, and family relationships. Secondly, often a home visit is the only way to involve the husband and/or other family members living at home in the therapeutic process. Thirdly, the home visit enables the therapist to validate the abuser perceptions of their home environment and the family relationships. Fourth, the therapist, after a home visit is able to make recommendations to the abusers as to physical structure and behavioral modifications necessary to eliminate variables which are reinforcing and/or precipitating abusive/neglectful behavior. The abuser will spend at the most two or three hours a week in the treatment center. The rest of their time is spent in there home and work habitat. The therapist must understand by experience the home and work habitat, which produced the abuser behavior in order to enable the abuser subject to better cope with their environment. Often one of the most important variables the therapist can investigate is the condition, quantity, quality, and type of foods in the home.

In discussing home visits, Savino and Sanders (1973) commented:

The author has also found that focusing on the child elicits from the parents their repressed feeling of hurt, desertion, and rage. The therapeutic process should always have as a primary goal the enabling of abusing parents to function on their own in providing a safe environment for their children without dependence upon the therapeutic team. As Savino and Sanders have pointed out: "only the parents can change the home environment." (p. 484)

One technique the author has found to be extremely useful in identifying variable, which are inhibiting family growth has been to develop a marital/family contract in writing. Without exception, the child abusers that the author has treated have reported that they did not work out a written marital/family contract. The only contract that was discussed by child abusers was 1) how many children they were going to have, 2) what their dream house was going to be like, and 3) that their love was a one and only love. Discussion of variables such as space maintenance, distribution of income, care of children, division of property, sexual behavior, relative relationship behavior, and food procurement were avoided both verbally and in writing by the child abusers the author has treated. Not only were these variables not discussed but also the abusers expressed hostility about reviewing these variables in their present relationship.

Abusers have not varied significantly in dealing with the realities of marriage and family from the general public as noted in the divorce courts. Marriages that begin in romantic love only most often end in contracts of divorce concerned with division of property, distribution of income and care of children.

Americans, especially the vulnerable young, have been programmed to believe in a distorted concept of love and marriage by Madison avenues and Hollywood concepts. The expectations that young people have of their marriages create an environment in which the marriage is bound to fail. Marriage licenses should not be issued until a written contract stipulating the parameters of childcare, distribution of income, division of property, relative relationship behavior, sexual behavior space maintenance and food procurement have been agreed to in writing. In addition to a written contract each couple should be required to enter pre-marital counseling to encourage a realistic view of marriage and parenthood. Another issue that must be addressed is the cultural expectation that abusers seem to fulfill more so than others of the isolated nuclear family. Our species social biological evolution has been the extended family. Only since the industrial revolution has the nuclear family come into existence. Perhaps one of the issues in the high divorce rates in which extended families are established through a step family system, is a biological adjustment to an unnatural cultural imposition called the nuclear family.

The following lengthy discussion by Barnett (1977) in regard to a treatment center encompasses a systems approach, which recognizes that therapeutic strategies for treatment of CAN must be eclectic. Unfortunately applied therapeutic techniques, which do not fall within the traditional "Psychoanalytic Model", are not considered payable benefits by the "Medical Reviewers" of third party insurance vendors. Even more insidious, is the awareness that the "Psychoanalytic Model" does not effect immediate behavioral change, which is necessary for treatment of abuse. Present discussions in the House and Senate of the U.S. Congress regarding National Health Insurance exclude provisions for outpatient psychotherapy. Until the American Medical Association is able to accept that the present guidelines dictated by them for payment of outpatient psychotherapy via third party health insurance vendors are invalid; treatment of child abusers in the United States will be impossible. The Y.M.C.A. project in San Diego would not be payable under present third party health insurance guidelines. In discussing the Y.M.C.A. treatment center in San Diego. Barnett (1977) stated:

The major treatment components utilized at the center are in keeping with the above educative approach and are the following:

Positive Parenting. A six to ten week training program, in which hundreds of parents have participated, solving models and communication styles. (Child are is provided for all participants.)

Parent Aides. Well-trained volunteers available four to ten hours weekly to visit in the home providing nurturing, support, skill-training, friendship, and modeling for various family members.

Emergency Caretakers. Well-trained paraprofessionals on call 24 hours a day, 7 days per week, to provide emergency and respite care to families in crisis. Also used as part-time homemaker/trainers to improve parental skills, protect children, and minimize the removal of children from their families.

Childcare Center. Designed to provide high-quality childcare and permit a respite or time-out, for parents on an interim or longer-term basis.

Individual and Family Counseling. Provided for family members when indicated and likely to be useful. The design of the treatment approach emphasizes the strengths of the individual family members and the dynamics of the family group in a growth and learning-oriented approach rather than on a pathology/historical model.

Marriage Group Counseling. A couples group where relationship issues are dealt with and the curative, change producing factors of group therapy (i.e.. universality, altruism, cohesiveness) as a delineated by Yalon (1970) are developed.

Child Development Group. A training group for parents conducted by a pediatric nurse wherein the issues of child development are presented and discussed.

Mother's Group. A weekly social gathering for mothers to share and socialize. Childcare is provided, there is no structural format, a staff member is made available and supportive systems among the mothers often develop.

Advocacy. Provided by the primary treatment worker on behalf of parents and children with other social agencies, the courts, hospitals, and medical practitioners. This is a collaborative model where the treatment workers have already begun to work with other involved agencies and make themselves available for court testimony, written report, and case management and consultation. Every effort is made to have clients preview reports and records as part of the treatment process.

Transportation. Provided for family members when needed for appointments, childcare and other needs in accord with staff availability.

Hochistadt and Harwicke (1985) in evaluating the multidisciplinary approach found that the Multidisciplinary team plays a central role in acquiring the services needed to reduce the deficits and sequels suffered by the victims of child abuse and neglect. Follow up care with Multidisciplinary was much better than with traditional method of CPS intervention. (Killen 1984)

Other therapist and researchers have found that traditional therapy with the identified patient is not as effective as family therapy, outreach, out of home placement, parent groups, and infant parent groups, and child parent groups. (Gagan et al 1984; Hairston 1985; Lindberg 1985; Parish et al 1985; Rivara 1985; Sankey et al 1985)

The phase "Quit the crying or I'll really give you something to cry about" is one that child abusers often heard in their childhood. This phase and others like it with the accompanying behavior of the parents is the genesis of most child abuse and violence in our culture. This phase is a primary program of our culture.

There are several elements of an animal behavior model discussed by Lorenz (1966) and Ulrich (1966) that apply to the abusing parent. Lorenz (1966) has observed that as the deprivation of a specific need increases, its corresponding drive increases, and the amount of stimulus necessary to elicit a response decreases. Ulrich (1966) has observed: 1) presentation of a painful stimulus will elicit a fight or flight response; 2) withdrawal of a positive reinforcer will elicit a fight or flight response; 3) the stronger the unconditioned stimulus is, the stronger the conditioned stimulus will be.

When the child abuser encounters a conditioned aversive stimulus in the environment (such as a behavior in his child that he had been punished for), the stimulus elicits a fight-flight response. The fight-flight response, as an unconditioned stimulus that has become a conditioned stimulus (through earlier punishment for fight-flight responses such as running away. crying, or at tacking) brings to consciousness an overwhelming rage response. The parent either directs the rage at the child batters it or runs away from the rage and neglects the child. The battering of the child reduces the parent's reservoir of repressed rage, and therefore acts as a positive reinforcer by reducing tension. The neglect of the child also reduces some tension since the parent removes himself from the conditioned aversive stimuli (the child); neglect, however, does not release the repressed rage from the parent.

Bettelheim (1950) calls this the phenomenon of identification with the aggressor. Steele and Pollock (1968) describe this phenomenon:

Suddenly a shift in identification occurs. The superego identification with the parent's owns punitive parent takes over. The infant is perceived as the parent's own bad childhood all that happened in the midst of such intense emotional turmoil. We interpret it as regression under severe stress to an early period of superego development when identification with the aggressor established a strict, punitive superego with more effective strength than the gentler ego ideal. In such a regressive state the stronger, punitive superego inevitably comes to the fore (p.131).

Each individual case requires personal treatment. The therapist must observe the family, which includes talking with and getting information from as well as watching the family. With this information the therapist can adapt the following general therapy plan to fit each family.

The first target of therapy is to teach the parent to release repressed rage in a way that does not hurt the child. Since the parent must respond to the child to raise it, the neglecting parent must encounter his rage too.

Directed Rage Reduction exercises can be taught to the abusing parents. The abusing parents are already redirecting their own repressed rage when they batter the child instead of venting the rage on the original source of the repressed pain. As part of the therapy, the parents are shown exercises that vent the rage on a substitute other than the child. The abusing parents are rewarded for imitating the model. Some rage-reduction exercises include attacking pillows or pads or similar things by pounding, spitting, whipping, beating, kicking, and biting while yelling, screaming, and crying. The exercises bring to consciousness the person's past painful memories. The exercises recreate the same internal conditions that were present when the person repressed his fight-flight response. The feelings the person has during the exercise are conditioned aversive stimuli. By repeatedly doing the exercises without being punished and learning to substitute them for attacking their children, the abusing parents learn to extinguish their fear and rage responses. While utilizing directed Rage Reduction techniques in the soundproofed, foam-padded room, the author has observed that male subjects will rage first and then cry, whereas female subjects will cry first and then rage. This is a functional of early childhood programming: Big good boys don't cry; good girls don't fight.

One Rage Reduction exercise used by William Schutz (1967) and modified and used by the author is as follows:

1) The Ss lays on his back on a bed or thick padding and closed his eyes to block out present stimuli and make regression easier for the whole experience;

2) Ss stretches. Yawns, relaxes completely, and hyperventilates (breath deep) several times;

3) Ss exhales and draws himself into a tight fetal position;

4) Ss concentrates his thoughts on a hate fantasy he has chosen; 5) takes a deep breath and slowly begins to release the fetal position;

 6) Ss at the same time slowly begins a soft moan and slowly begins moving his arms and legs back and forth;

7) Ss gradually goes from a slow deliberate movement and a soft moan to a very rapid movement and a scream;

8) Ss repeats this as many times as he wants to.

Several points should be stressed:

1) Instruct Ss not to hurt himself, and get more padding if Ss cannot kick and pound without hitting the floor;

2) instruct Ss to remember to breath during the exercise;

3) instruct Ss that yelling, screaming, and breathing will be easier if he keeps his head back so that his throat is open. The more comfortable and relaxed Ss are in the environment where the rage takes place, the deeper inside himself the Ss will go when he regresses. While Ss is learning and doing the rage exercise, he should be protected from being punished. The Ss wi11 be fighting his f ear of punishment in order to allow himself to do the rage exercise. After Ss feels relaxed enough in doing the rage exercise to allow himself to get to some deep hurt inside himself. Ss will lie on the pads bawling, crying, and sobbing when he finishes raging (Ss lets out the response he repressed when he was told to "quit that crying"). The Ss should be gently touched and petted by someone during this stage. If Ss's mate is available, the mate can touch Ss. If the exercise takes place among a group of people, they can touch Ss in addition to his mate. Some other exercises that bring to consciousness the Ss's past painful memories work by recreating external stimuli similar to those presents when the person repressed his fight-flight response. Some of these exercises include having a group of people provide the prompts. Often a gentle petting from family members (also known as primate grooming behavior) will be extremely productive. The Ss can tell the group members which words or behaviors create fear and rage responses in them.

As the Ss gets more skilled at these exercises, he should be encouraged to set up a place in his home where he can do them on his own. If a situation arises at home where Ss go into a rage response, he should have a place where he can direct his response away from the children. This place could be a corner with pads and pillows. Or, it could be a closet lined with polyfoam padding.

The first target of therapy is to redirect the parent's rage away from the child. The second target is to teach the parents to give to and receive from their children and each other non-hostile attention, praise, and love and affection. Again, this can be done by rewarding the parents and their children for imitating a model. The model would preferably be a whole family. Then the abusing parents and their children would be encouraged to imitate the model while in the therapy session and at home while they are alone. The family can be shown to praise each other for desired behavior, to hold and touch each other affectionately, and to listen and respond to each other's needs. This will give family members a new way to respond to each other, which will make raging a less useful tool to manipulate other family members.

Third, the abusing parents can be taught to observe their own behavior and the behavior of their children. It is important that the parents learn to recognize the stimuli that precede and follow the attacks on or neglect of the child. When the crying and raging exercises have been substituted, the parents can learn to recognize the stimuli preceding, during, and following the exercises. In this way, the parents can learn to understand themselves and their children more completely and may be able to manipulate their own environments to reduce their stress and abusive behavior.

Fourth, the parents can be taught to recognize and understand their needs and the needs of their children. This can be done by supplying information about and teaching both parents where they can get information on: 1) reproduction -. from mate seeking through conception, pregnancy, birth, and rearing a child to survive. 2) food and nutrition; 3) money making; 4) space maintenance; 5) avoidance of pair-I; 6) defense; 7) and pleasure. With this information the parents are more able to manipulate their environments to reduce their stress and abusive behavior.

Fifth, abusing parents can be reinforced to be aware of their capacity for giving and their family's capacity for needing. The parents must learn to recognize how much energy they have and decide how the energy will be spent.

Sixth, abusing parents often reject each other and try to get their needs satisfied through their children. Abusing parents can be rewarded for satisfying their needs with each other and sharing with each other.

One important prevention strategy is to increase public awareness about child sexual abuse. Prevention programs for victims may be effective if the public views the sexual abuse as a problem relevant in their communities. Specific goals to prevention are to educate the public about child sexual abusers and to motivate adults to action to prevent child sexual abuse.

A complete physical examination of prepubertal children should always include a genital examination. Sexually abused children may be identified through routine review of systems and history, including behavioral and psychosocial, and open-ended questions regarding sexual abuse. Reassurance from a trusted practitioner relating to a normal body can be the most valuable treatment for a child’s emotional healing. Practitioners need to be aware of the resources in their community for medical evaluations for sexual abuse, legal investigations, and mental health referrals (Botash, 1997).

Cohen (1996) findings of the role of demographic, developmental, and familial mediating factors on treatment outcome of sexually abused preschool children indicate a strong correlation between parental emotional distress related to the abuse and treatment outcome in the children, independent of the type of treatment provided. Cohen (1996) concluded "The findings indicate the importance of addressing parental distress related to the abuse in providing effective treatment to sexually abused children".

Research shows that individual treatment for the sexually abused is more efficacious than group therapy. An evaluation study of the impact of the treatment program for forty-one sexually abused children (aged 6 to 17 years), victims of child abuse by a family member, assessed at pre and post-treatment (16 months following pre-test). The evolution of children’s psychological well-being was measured by the Children’s Depression Inventory (CDI), the Pictorial Scale of Perceived Competence and Acceptance for Young Children (PSPCA), the Children’s Norwicki-Strictland Internal-External control scale (CNS I-E), the Children’s Action Tendency Scale (CATS), the Revised Children’s Manifest Anxiety Scale (RCMAS), and the Pediatric Behavior Scale (PBS). Results indicate that the child’s mental health was generally positively related to the level of participation in individual therapy but not related or negatively related with the level or participation in group sessions except for the PBS. These results indicate the need to consider the adoption of a dose measurement in the appreciation of therapeutic impact. "A better grasp of the nature and the effects of specific therapeutic activities need to be included in a program. Better understanding of the disparities observed between parents’ and children’s evaluation of the psychological status of the child is needed" (Tourigny, P’eladeau, Doyon, & Bouchard, 1998).

Animal assisted therapy is an effective tool in conducting individual counseling for sexually abused children. Through these animals, the sexually abused child will feel at ease with social workers and is able to release feeling and disclose the sexual experience. Storytelling involving the animal is also useful with this therapy. "However, this kind of treatment cannot be applied to all children, especially those with history of aggression towards animals" (Reichert, 1998).

The key aspect of psychotherapy involves helping the victim to see that the need to reenact the trauma is a way of defending against anxiety and confusion. The young abuse victim is encouraged to explore both the positive and negative aspects of feeling for the abuser. Ellis, Piersma, & Grayson (1990) report: "Individual therapy gives the victim a context for the expression of ambivalent feelings".

One of the most difficult abuse problems to treat has been the Physical Abuse of the teen-age girl by the father. The attack has been most often precipitated by the girl coming home late from a date. The father, who has been usually drunk, punches the daughter in the breast often cracking or breaking her ribs. The father has been in an incestuous rage and feels quite justified in hitting her. The parents usually have not had sexual relations for years and the father most often refuses to come in for therapy,

If the father and mother will come in for treatment, then progress can be made. The fathers that have agreed to come in for treatment state that their daughter has been "the only person that they really ever loved" and that t hey and their spouse have not been happy with each other for years. In addition the father has had sexual desires for his daughter for years and when she develops into a young women with accompanying adolescent exhibitionism which stimulates him, coupled with his extreme feelings of guilt, he attacks.

One of the most useful therapeutic techniques the author has used with incestuous rage has been a Combination of directed rage reduction and the use of the Show Me. a picture book of sex for children and parents. The author will see the mother and father individually first, going through the book Show Me. and then conjointly repeating the process with the parents looking through Show Me together and discussing the contents. The father often state that Show Me is a bad and dirty book even though later he admits to sexual promiscuity before and after the marriage.

An additional aspect of incestuous rage, which also is manifested in sexual abuse, is the disapportionate number of stepfathers who incestuously abuse their stepdaughters when compared to natural fathers. (Russell 1984) The sexual abuse of stepdaughters appears to be linked with the genetic primate behavior of dominance manifested in eliminating of male offspring of the defeated rival and copulating with the female offspring (Howell 1968; Morris 1967;) As a preventive measure, couples who are about to remarry with dependent children must be counseled about this aspect of our genetic behavior.

Once the father can accept that it is normal for fathers to have desires for their daughters and positive sexual experiences are reinstated between the parents then a conjoint family session is held with the children.

When the father refuses to become involved in therapy the author attempts to give the mother an understanding of the dynamics involved and encourages her to reestablish a marital relationship.

Unfortunately, the author has had a number of cases in which to only solution was the removal of the father from the home via separation and divorce. This phenomenon of incestuous rage occurs frequently in the just retired military family. The father has been a chronic alcoholic who has spent the majority of his time away from the family and upon retirement attempts to assert - military fashion - authority over a family that has been independent of him for 15 years. The father, who has relied upon the service to control his behavior and right his wrongs, is left with no internal constraint upon retirement. He frequently has been unable to obtain satisfactory employment and feeling frustrated at home drinks his retirement check up. Primary in the military father has been the belief that he is supposed to be dominant in his household. The struggle for dominance has been very common in abusing families and has been a continual source of family conflict. In analyzing the relationship of dominance to abuse. Weinburg (1975) stated:

Learning to live without hierarchy and equitable distribution of power will take a long time, but could probably bring a change in family conflict and hopefully, an end to the frustration and violence that is now called "child abuse" (p. 32).

Often, the author has held military combat veterans in his arms, while they have cried and sobbed about their hurt, fear and loneliness. Far too often, the sympathy and understanding that child abusers need is withheld from the father. Women's movements sometimes forget that the male has been subject to the same influence and controls to be dominant as the woman has been to subordinate.

Men have as much need to be held and comforted as women; only they have been programmed from early childhood that they should not express or seek warmth and tenderness in their lives. Often the author has observed that the only time an abusing father allows himself any warmth and affection has been during coitus. Without exception, the abusing fathers whom the author has treated believe they should not be warm and affectionate with their children, especially their sons.

In a report released by the Department of Health Education, and Welfare (1976) the following was stated:

Somewhere between the goals of practical men and those with visionaries lies the area of primary prevention. A community with a well-coordinated program of identification, treatment, and education directed toward the problem of child maltreatment has already initiated preventive measures, although these can prevent abuse and neglect in only a secondary way-by limiting its extent and recurrence. Primary prevention focuses on preventing the first occurrence of child abuse or neglect in a family (P. 153).

Some professionals doubt that complete prevention of child maltreatment is even possible. It would require, they say. a total change in our social fabric, the creation of Utopia. Other considers primary prevention a more or less reachable goal. They propose that, while the abuse and neglect of children may never be completely eliminated, there are definite steps a well-coordinated community can take in the direction of this object (p. 154).

The author agrees that the elimination of child abuse will require a complete change in the social fabric of our culture and then the world culture. As we enter the technological evolution of the cultural the demand for intelligence, creativity and maturity will prevail in all social economic groups demanding the change in present childhood rearing practices. Let us hope that this requirement for societal survival will indeed spur the process of change. The work of thousands of dedicated health workers will be required. The following chapter outlines a research -treatment project that can provide a model for a community treatment center.